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OF    TH  E 

•School  oj^i^edicine. 


Presented.  By 


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SURGICAL  PAPERS 

BY 

WILLIAM  STEWART  HALSTED 

1852-1922 


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SURGICAL  PAPERS 

BY 

WILLIAM  STEWART   HALSTED 


IN  TWO  VOLUMES 


VOLUME  ONE 


BALTIMORE 

THE  JOHNS  HOPKINS  PRESS 

MDCCCCXXIV 


€§e  £ori  (^afttmorc  (pvees 

BALTIMORE,  MD„  U.  S.  A. 


,  QoU. 

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27854 


IN  HONOR  OF 

WILLIAM  STEWART  HALSTED 

1852-1922 

THIS  COLLECTED  EDITION 

OF  HIS  PAPERS  AND  ADDRESSES  IS  PUBLISHED 

AS  A  MEMORIAL  OF  LOVE,  ESTEEM,  AND  INDEBTEDNESS 

BY  HIS  ASSOCIATES  AND  PUPILS 


EDITOR'S  NOTE 

The  late  Dr.  William  Stewart  Halsted,  who  was  Professor  of 
Surgery  in  The  Johns  Hopkins  University  and  Surgeon-in-Chief 
of  The  Johns  Hopkins  Hospital  from  the  date  of  its  opening  in 
1889  until  his  death  on  September  7,  1922,  would  have  been 
seventy  years  old  on  the  twenty-third  of  that  month.  A  commit- 
tee of  his  colleagues  had  decided  that  the  most  suitable  com- 
memoration of  this  anniversary  would  be  the  publication  of  his 
collected  papers  which,  as  is  known,  was  the  form  of  recognition 
most  acceptable  to  Dr.  Halsted  himself.  And  now  these  volumes 
are  held  to  be  a  fitting  memorial  of  Dr.  Halsted 's  life  and  work. 

When  one  considers  the  number,  originality,  and  importance 
of  Dr.  Halsted 's  contributions  to  surgery  during  the  last  forty 
years,  which  have  placed  him  in  the  front  rank  of  modern  sur- 
geons, and  their  scattered  and  often  not  readily  accessible  form 
in  journals  and  reports,  it  is  realized  that  this  publication  not 
only  constitutes  a  worthy  tribute  to  his  memory  but  also  renders 
a  much  needed  service  in  making  available  these  significant 
contributions. 

The  volumes  reveal  the  important  part  played  by  their  author 
in  the  advance  of  modern  surgery  during  a  period  of  great 
progress  which  was  stimulated  by  the  discovery  of  anaesthesia 
and  infectious  microorganisms.  Dr.  Halsted 's  distinct  published 
contributions  include:  blood  refusion  by  centripetal  arterial 
transfusion  in  carbonic  oxide  poisoning ;  the  effect  of  adduction 
and  abduction  on  the  length  of  the  limb  in  fractures  of  the  femur ; 
the  employment  of  fine  silk  in  preference  to  catgut  and  the  ad- 
vantages of  transfixing  tissues  and  vessels  in  controlling  haemor- 
rhage; the  introduction  of  rubber  gloves,  gutta  percha  tissue, 
silver  foil,  the  mattress  intestinal  suture,  and  the  subcuticular 
stitch ;  special  emphasis  of  the  blood  clot  in  the  management  of 
dead  spaces  in  the  treatment  of  wounds  which  has  led  to  its  more 
widespread  use  and  appreciation ;  the  open-air  treatment  of  sur- 


viii  EDITOR'S  NOTE 

gical  tuberculosis;  the  introduction  of  conduction  (so-called 
block)  anaesthesia ;  circular  and  lateral  intestinal  anastomoses ; 
the  bulkhead  method  of  end-to-end  intestinal  suture ;  the  blind- 
end  circular  suture  of  the  large  intestine,  the  closed  ends  abutted 
and  the  double  diaphragm  punctured  with  a  knife  passed  per 
rectum;  original  operations  for  the  radical  cure  of  inguinal 
hernia,  cancer  of  the  breast,  goitre,  aseptic  intestinal  anasto- 
mosis; the  partial,  progressive,  and  complete  occlusion  of  the 
aorta  and  other  large  arteries  by  metal  bands  in  the  cure  of 
aneurism;  the  relation  of  dilation  of  the  subclavian  artery  to 
cervical  rib ;  the  successful  ligation  of  the  left  subclavian  in  its 
first  portion  for  the  cure  of  a  huge  subclavian  aneurism;  the 
transplantation  of  the  parathyroids ;  the  retrojection  of  bile  into 
the  pancreas  as  a  cause  of  acute  haemorrhagic  pancreatitis ;  the 
omission  of  drainage  in  common-duct  surgery;  a  method  of 
closure  of  the  cystic  duct  after  excision  of  the  gall-bladder: 
Thiersch  skin-grafts  after  radical  breast  amputations ;  and  the 
replantation  of  entire  limbs  without  vessel  suture. 

Starting  with  the  author's  first  published  contribution  "  Blood 
refusion  in  the  treatment  of  carbonic  oxide  poisoning  "  the 
papers  on  similar  subjects,  although  scattered  over  a  number  of 
years,  have  been  placed  together  chronologically  in  groups.  An 
attempt  has  been  made  to  unify,  in  a  form  preferred  by  Dr. 
Halsted,  the  varying  orthography  of  the  different  books  and 
journals. 

In  behalf  of  the  Committee  the  editor  wishes  to  thank  editors 
and  publishers  of  books  and  periodicals  for  their  hearty  consent 
to  the  use  of  articles  and  illustrations  appearing  in  these  vol- 
umes. A  great  debt  of  appreciation  is  due  to  Dr.  Rudolph  Matas 
for  permission  to  use  his  memorial  tribute  to  Dr.  Halsted  as  the 
introduction  to  the  volumes.  To  The  John  Crerar  Library  for 
the  free  use  of  its  books,  to  Mr.  D.  Chong  Chun  of  Hawaii  for 
his  assistance  in  proof-reading  and  to  the  many  associates  and 
friends  of  Dr.  Halsted  who  have  given  valuable  help,  the  editor 
acknowledges  his  indebtedness. 

Walter  C.  Burket,  Editor. 
January,  1928. 


TABLE  OF  CONTENTS 

PAGE 

Editor's  Note vii 

Introduction:  William  Stewart  Halsted  (1852-1922) — An  Appre- 
ciation        xv 

BLOOD  REFUSION  AND  TEANSFUSION 

Refusion  in  the  Treatment  of  Carbonic  Oxide  Poisoning 3 

Centripetal  Arterial  Transfusion 13 

Centripetal  Arterial  Transfusion 14 

THE  EFFECT  OF  ADDUCTION  AND  ABDUCTION  ON  THE 

LENGTH  OF  THE  LIMB  IN  FRACTURES  OF 

THE  NECK  OF  THE  FEMUR 

Adduction  and  Abduction  in  Fractures  of  the  Neck  of  the  Femur.  ...     17 
The  Effects  of  Adduction  and  Abduction  on  the  Length  of  the  Limb  in 

Fractures  of  the  Neck  of  the  Femur 19 

SURGICAL  TECHNIC.    ASEPTIC  AND  ANTISEPTIC 

SURGERY 

The  Employment  of  Fine  Silk  in  Preference  to  Catgut  and  the  Advan- 
tages of  Transfixing  Tissues  and  Vessels  in  Controlling  Haemor- 
rhage. Also  an  Account  of  the  Introduction  of  Gloves,  Gutta- 
percha Tissue  and  Silver  Foil 29 

Aseptic  Surgery  in  New  York  in  1884 46 

Incision  for  Nephrectomy 47 

A  Needle-Holder  for  Hagedorn's  Needles 49 

The  Introduction  of  "  Gut- Wool,"  and  a  Review  of  the  Book  "  Anleit- 

ung  zur  Aseptischen  Wundbehandlung  " 50 

The  Operative  Reduction  of  an  Old  Dislocation  of  the  Elbow 55 

Two  Cases  of  Excision  of  the  Knee-Joint  in  Which  Hansmann's  Plates 

with  Ordinary  Screws  were  Employed 56 

Concerning  Inflammation  and  Suppuration 58 

Bichloride  Irrigations    61 

Concerning  Drainage  and  Drainage  Tubes 63 

Carrel-Dakin  Method  of  the  Treatment  of  Infected  Wounds.  Antisep- 
tics in  the  Aseptic  Period 64 

ix 


x  TABLE  OF  CONTENTS 

THE  BLOOD  CLOT  IN  THE  MANAGEMENT  OF  DEAD 
SPACES  IN  THE  TREATMENT  OF  WOUNDS 

PAGE 

The  Treatment  of  Wounds  with  Especial  Reference  to  the  Value  of  the 

Blood  Clot  in  the  Management  of  Dead  Spaces 71 

Unclassified  Operations   77 

Operations  for  Tuberculosis  of  Bones  and  Joints 83 

Excision  of  Tuberculous  Lymphomata 85 

Operations  for  Carcinoma  of  the  Breast 87 

Operations  for  the  Radical  Cure  of  Inguinal  Hernia  in  the  Male.  .  .  89 

Amputations  of  the  Thigh 91 

Arthrodesis  for  Paralytic  Flail- Joints 91 

Trendelenburg-Hahn  Operation  for  Flat  Foot 92 

Operations  for  Ununited  Fractures 92 

Operations  for  Fractures  of  the  Patella 93 

Osteotomy  for  Bow  Legs 93 

Incision  and  Irrigation  of  Joints  for  Gonorrhoeal  Arthritis 94 

Extirpation  of  Inguinal  Glands  for  Gonorrhoeal  Adenitis 94 

Operations  for  Syphilis  of  Bones 95 

Necrotomies  and  Operations  for  Bone  Abscesses 96 

Extirpation  of  Varicose  Veins  of  the  Leg  and  Thigh 98 

Operations  for  the  Removal  of  Cysts  and  New  Growths 99 

Crush  of  Elbow — Organization  of  Blood  Clot 113 

Plastic  Operation  for  the  Obliteration  of  a  Large  Cavity  in  the  Lower 

End  of  the  Femur 114 

A  Suppurating,  Compound,  Comminuted  Fracture  into  the  Ankle  Joint 

Treated  without  Drainage 115 

THE  SURGERY  OF  FOREIGN  BODIES 

Removal  of  Foreign  Bodies : 

I.  A  Piece  of  Fibro-Cartilage  Removed  from  the  Oesophagus  by 

External  Oesophagotomy  119 

II.  Three  Calculi,  Each  with  a  Portion  of  a  Soft  Catheter  as  a 
Nucleus,  Removed  from  the  Bladder  by  Lateral  Lithotomy 

at  One  Operation 119 

III.  A  Portion  of  a  Bullet  Removed  from  the  Diploe  and  Cranial 

Cavity     119 

Successful  Removal  of  Large  Foreign  Body  from  the  Head 121 

A  Contribution  to  the  Surgery  of  Foreign  Bodies : 

I.  Stellate  Calculi  in  Form  Resembling  Jackstones  Removed  from 

the  Bladder  by  Suprapubic  Lithotomy 122 


TABLE  OF  CONTENTS  xi 

PAGE 

II.  Two  Hundred  and  Eight  Foreign  Bodies  and  Seventy-Four 
Grammes  of  Glass  Extracted  from  the  Stomach  by  Gas- 
trotomy.    Recovery   122 

SURGICAL  TREATMENT  OF  TUBERCULOSIS 

Cases  of  Partial  Resection  of  the  Elbow  and  Shoulder  for  Tuberculosis, 

and  of  the  Ankle  for  Traumatism 135 

A  Tuberculous  Knee-Joint 138 

Excision  of  One-Half  (Anterior)  of  the  Head,  Neck,  and  Upper  Portion 
of  the  Trochanter  of  the  Right  Femur  by  Frontal  Section  for 
Tuberculosis  of  the  Hip- Joint 139 

Results  of  the  Open- Air  Treatment  of  Surgical  Tuberculosis 142 

CONDUCTION  ANAESTHESIA 

Practical  Comments  on  the  Use  and  Abuse  of  Cocaine;  Suggested  by 
Its  Invariably  Successful  Employment  in  More  Than  a  Thou- 
sand Minor  Surgical  Operations 167 

Water  as  a  Local  Anaesthetic 167 

Local  Anaesthesia  with  Weak  Solutions  of  Cocaine 178 

SURGERY  OF  THE  INTESTINES 

A  Case  of  Intestinal  Incarceration 181 

Circular  Suture  of  the  Intestine.   An  Experimental  Study 185 

Intestinal  Anastomosis    212 

Recurrent  Volvulus    220 

A  Diagnostic  Sign  in  Appendicitis 222 

A  Postscript  to  the  Report  on  Appendicitis 224 

Inflated  Rubber  Cylinders  for  Circular  Suture  of  the  Intestine 227 

End-to-End  Suture  of  the  Intestine  by  a  Bulkhead  Method.  Prelimi- 
nary Communication    233 

A  Bulkhead  Suture  of  the  Intestine 238 

An  End-to-End  Anastomosis  of  the  Large  Intestine  by  Abutting  Closed 
Ends  and  Puncturing  the  Double  Diaphragm  with  an  Instru- 
ment Passed  Per  Rectum 246 

Blind-End  Circular  Suture  of  the  Intestine,  Closed  Ends  Abutted  and 
the  Double  Diaphragm  Punctured  with  a  Knife  Introduced 
Per  Rectum  249 


xii  TABLE  OF  CONTENTS 

THE  OPERATIVE  TREATMENT  OF  INGUINAL  HERNIA 

PAGE 

The  Radical  Cure  of  Hernia 261 

The  Radical  Cure  of  Hernia 263 

Excision  of  Some  of  the  Veins  of  the  Cord  in  the  Operation  for  the 

Radical  Cure  of  Inguinal  Hernia 264 

The  Radical  Cure  of  Inguinal  Hernia  in  the  Male 265 

Report  of  Twelve  Cases  of  Complete  Radical  Cure  of  Hernia,  by 
Halsted's  Method,  of  Over  Two  Years'  Standing.  Silver  Wire 

Sutures  283 

The  Operative  Treatment  of  Hernia 286 

The  Operative  Treatment  of  Hernia 291 

The  Cure  of  the  More  Difficult  as  well  as  the  Simpler  Inguinal  Ruptures  292 
An  Additional  Note  on  the  Operation  for  Inguinal  Hernia 306 

SURGERY  OF  THE  BLOOD  VESSELS  AND  EXPERIMENTAL 
SURGERY  OF  THE  LUNGS 

Ligation  of  the  First  Portion  of  the  Left  Subclavian  Artery  and  Exci- 
sion of  a  Subclavio- Axillary  Aneurism 311 

The  Partial  Occlusion  of  Blood  Vessels,  Especially  of  the  Abdominal 

Aorta.    A  Preliminary  Report 314 

The  Results  of  the  Complete  and  Incomplete  Occlusion  of  the  Abdomi- 
nal and  Thoracic  Aortas  by  Metal  Bands 318 

Clinical  and  Experimental  Contributions  to  the  Surgery  of  the  Thorax.   321 

Partial  Occlusion  of  Large  Arteries  by  Aluminum  Bands 325 

The  Effect  of  Ligation  of  the  Common  Iliac  Artery  on  the  Circulation 
and  Function  of  the  Lower  Extremity.  Report  of  a  Cure  of  Ilio- 
Femoral  Aneurism  by  the  Application  of  an  Aluminum  Band  to 
That  Vessel  329 

A  Case  of  Ilio-Femoral  Aneurism  Exemplifying  the  Value  of  the  Pre- 
liminary Partial  Occlusion  of  an  Artery  in  the  Treatment  of 
Aneurism    398 

Partial,  Progressive,  and  Complete  Occlusion  of  the  Aorta  and  Other 

Large  Arteries  in  the  Dog  by  Means  of  the  Metal  Band 401 

Partial  Occlusion  of  the  Thoracic  and  Abdominal  Aortas  by  Bands  of 

Fresh  Aorta  and  of  Fascia  Lata 417 

Der  Partielle  Verschluss  Grosser  Arterien 421 

As  to  the  Cause  of  the  Dilatation  of  the  Subclavian  Artery  in  Certain 

Cases  of  Cervical  Rib — Experimental  Study 435 


TABLE  OF  CONTEXTS  xiii 

PAGE 

An  Experimental  Study  of  Circumscribed  Dilation  of  an  Artery  Imme- 
diately Distal  to  a  Partially  Occluding  Band,  and  Its  Bearing  on 
the  Dilation  of  the  Subclavian  Artery  Observed  in  Certain  Cases 
of  Cervical  Eib 43? 

Partial  Occlusion  of  the  Aorta  with  the  Metallic  Band.    Observations 

on  Blood  Pressures  and  Changes  in  the  Arterial  Walls  (Beid) .  .   453 

The  Ideal  Operation  for  Aneurism;  A  Case  of  Lyrnphangiomatous  Cyst  45? 

Cylindrical  Dilation  of  the  Common  Carotid  Artery  Following  Partial 

Occlusion  of  the  Innominate  and  Ligation  of  the  Subclavian . . .  460 

Dilation  of  the  Great  Arteries  Distal  to  Partially  Occluding  Bands 469 

Congenital  Arterio- Venous  and  Lymphatico- Venous  Fistulae.    Unique 

Clinical  and  Experimental  Observations 476 

Ligations  of  the  Left  Subclavian  Artery  in  Its  First  Portion 483 

A  Striking  Elevation  of  the  Temperature  of  the  Hand  and  Forearm 
Following  the  Excision  of  a  Subclavian  Aneurism  and  Ligations 
of  the  Left  Subclavian  and  Axillary  Arteries 573 

The  Effect  on  the  Walls  of  Blood  Vessels  of  Partially  and  Completely 

Occluding  Bands 585 


y-/jf-f.j,    .7)  "///,,>,  ,; 


iO-vXa/,  u<£~ 


WILLIAM  STEWART  HALSTED 

1852-1922 

AN  APPRECIATION  * 

When  I  accepted  the  gracious  invitation  of  President  Goodnow  to  join  the 
friends  of  Professor  Halsted  in  a  public  tribute  to  his  memory,  I  did  so 
gladly  and  gratefully.  Indulging  in  no  vain  illusion  that  anything  which  I 
might  say  could  add  weight  to  such  merits  and  virtues  as  have  exalted  his 
acknowledged  rank,  nor  that,  by  any  grace  of  speech,  I  might  place  further 
emphasis  upon  the  eloquence  of  those  far  abler  to  express  the  sentiments  of 
affection  and  admiration  which  Dr.  Halsted  inspired,  I  was  conscious,  never- 
theless, that,  although  one  of  the  least  worthy  among  his  friends  and  admir- 
ers, none  other  would  come  to  this  gathering  whose  heart  overflowed  with 
greater  gratitude  and  appreciation. 

Few  have  been  permitted  to  enjoy  such  immeasurable  good  as  came  to  me 
through  him.  Not  only  profiting  by  his  sympathy,  counsel  and  experience 
in  a  way  far  exceeding  the  benefits  that  have  accrued  to  many  of  his  nearer 
colleagues  and  associates — benefits  that  have  contributed  in  no  small  mea- 
sure to  my  professional  enlightenment  and  improvement — I  also  owe  him  a 
debt  which  is  far  more  direct  and  personal,  a  debt  that  cannot  be  estimated 
nor  expressed  in  mere  words.  In  his  lifetime,  he  had  rendered  me  a  service 
in  which  his  surgical  skill  and  kindness  had  united  to  relieve  me  of  a  heavy 
burden — thereby  making  my  travel  through  life  much  lighter,  and  intro- 
ducing contentment  and  confidence  where  previously  there  had  been  only 
uncertainty,  danger  and  doubt.  It  is,  therefore,  as  a  debtor,  in  more  than 
one  sense,  that  I  am  here,  seeking  to  repay  that  which  I  can  never  hope  to 
return,  even  in  small  installments. 

Though  not  of  Dr.  Halsted's  official  family,  and  with  no  claim  to  recogni- 
tion as  one  of  his  pupils  and  associates,  I  feel  that,  through  the  ties  of  strong 
affection  that  bound  me  to  him,  I  am  entitled  to  wear  the  badge  of  mourning 
which,  if  not  outwardly  displayed,  is  well  wrapped  around  my  heart. 

You  will  pardon  this  allusion  to  my  personal  relations  with  Dr.  Halsted. 
It  has  no  other  purpose  than  to  disclaim  any  pretense  to  exploit  my  friend- 

*  An  address  by  Dr.  Rudolph  Matas,  Professor  of  Surgery,  Tulane  University,  New 
Orleans,  La.,  delivered  on  the  occasion  of  the  memorial  meeting  for  Dr.  William 
Stewart  Halsted,  held  at  Homewood,  December  16,  1923. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1925,  XXXVI,  2. 

xv 


xvi  WILLIAM  STEWAET  HALSTED 

ship  for  him  or  the  warm  feeling  that  I  have  every  reason  to  believe,  he  enter- 
tained for  me ;  nor  any  motives  that  might  redound  to  my  own  advantage ; 
nor  that  I  might  assume  the  privilege  of  acting  as  his  biographer  on  this 
occasion.  Even  though  this  function  were  becoming  in  me,  this  is  not  the 
time  nor  place  in  which  to  exercise  it.  That  must  be  the  sacred  part  of  those 
who  dwelt  in  close  and  intimate  association  with  Dr.  Halsted;  who  living 
with  him  in  daily  communion,  participating  in  the  routine  activities  of  his 
life,  are  privileged  to  write  a  biography  that  will  do  justice  to  his  labors  and 
to  his  personality.  This  task  has  been  in  some  measure  accomplished  in 
the  appreciative  notices  which  have  recently  appeared  over  the  signatures 
of  two  of  his  most  eminent  associates  and  co-workers,  Drs.  Cushing  and 
Finney.  These  two  admirable  sketches  suffice  to  acquaint  those  who  did  not 
know  Dr.  Halsted  personally  with  the  outstanding  facts  of  his  life,  his 
antecedents  and  personal  characteristics;  but  to  an  audience  like  this,  com- 
posed largely,  if  not  wholly,  of  Dr.  Halsted's  friends,  assembled  within  the 
walls  of  the  institution  which  still  resounds  with  the  familiar  echoes  of  his 
voice  and  retains  much  of  the  warmth  of  his  loved  presence — a  rehearsal  of 
such  well  known  facts  would  be  like  bringing  coals  to  Newcastle — a  superflu- 
ous undertaking.  I  shall,  therefore,  dispense  with  purely  biographic  details 
which  in  the  main  I  should  have  to  borrow  from  others  more  competent  to 
speak,  and  I  will  confine  myself  to  a  simple  appreciation  of  his  life  from 
the  viewpoint  of  one,  who,  looking  at  him  from  a  distance,  kept  in  close 
touch  with  his  work  and  felt  a  deep  interest  in  his  professional  achieve- 
ments; who  felt  for  him  that  warm  sympathy  which  is  engendered  by  a 
veneration  akin  to  that  of  the  pupil  for  a  beloved  master ;  who  felt  for  him 
all  the  loyalty  and  sincerity  of  a  grateful  friendship,  and  all  the  congeniality 
which  is  born  of  a  communion  of  ideas  and  mutual  interests  in  a  common 
field  of  endeavor. 

What  I  shall  have  to  say,  at  this  moment,  is  largely  prompted  by  the  very 
exuberance  of  my  affection,  by  the  very  joy  of  speaking  of  him,  and  out  of 
the  fullness  of  my  admiration. 

We  know  enough  to  assert  his  greatness  without  fear  of  exaggeration, 
but  it  is  our  successors,  and  the  generations  that  will  follow  them,  who,  in 
the  light  of  history,  will  assign  to  him  its  full  and  just  measure. 

* 
*        * 

My  interest  in  Professor  Halsted  began  early  in  my  professional  career, 
when  the  distinctive  qualities  of  his  work  had  begun  to  attract  attention, — 
foreshadowing  his  future  eminence  as  one  of  the  leading  lights  of  surgery 
in  this  country.  It  was  late  in  the  eighties,  when  all  eyes  were  turned  towards 


AN  APPRECIATION  xvii 

Baltimore,  where  the  directing  genius  of  Dr.  John  Shaw  Billings  had 
planned  and  laid  the  foundation  for  a  medical  school  destined  to  revolu- 
tionize all  previous  concepts  and  standards  of  hospital  organizations  in 
America.  As  Director  of  the  Surgeon  General's  Library  in  Washington, 
Dr.  Billings'  kindness  and  encouragement  to  the  young  men  who  frequented 
the  Library  is  gratefully  remembered  by  all  who,  like  myself,  were  the 
recipients  of  his  favor  while  he  was  the  inspiring  and  generous  custodian  of 
that  priceless  repository  of  medical  lore.  It  was  through  Dr.  Billings  that 
it  was  my  good  fortune  to  attend  the  opening  exercises  which  inaugurated 
The  Johns  Hopkins  Hospital  in  1889,  and  it  was  from  that  eventful  year 
that,  chiefly  through  my  devotion  to  Dr.  Billings  and  my  interest  in  the 
success  of  his  enterprises,  there  developed  a  sympathy  and  affection  for  this 
institution  which  has  grown  stronger  ever  since. 

I  cannot  refer  to  those  early  days  without  rubbing  my  eyes  to  visualize 
more  clearly  the  great  length  of  the  path  over  which  Medicine  has  traveled 
in  that  short  span  of  scarcely  four  decades  which  have  elapsed  since  the 
vigorous  seed  planted  by  the  generous  Hopkins  has  grown  into  the  stately 
tree  that  is  giving  us  shelter  today.  But,  we  cannot  reflect  upon  the  stupen- 
dous progress  accomplished  during  this  period  in  the  history  of  American 
medical  institutions,  without  evoking  the  image  of  that  group  of  supermen — 
the  great  quadrumvirate,  Welch,  Osier,  Halsted,  Kelly,  and  their  asso- 
ciates— who,  by  virtue  of  their  example  and  achievements  in  this  institution 
have  exercised  the  most  profound  and  salutary  influence  in  directing  and 
stimulating  the  medical  profession  of  this  country  to  the  attainment  of  its 
present  high  aims  and  ideals. 

It  was  not  until  1903,  just  twenty  years  ago,  that  I  first  came  to  know 
Dr.  Halsted  in  the  light  of  his  personal  attributes  as  a  man.  Up  to  that 
time,  I  had  become  familiar  only  with  his  scientific  attitude  of  mind,  and, 
like  every  other  surgeon  in  the  country  who  is  interested  in  the  progress  of 
his  profession,  I  had  been  impressed  with  the  importance  of  his  researches, 
the  originality  of  his  ideas,  and  the  thoroughness  of  his  practice.  We  had 
met  casually  at  the  meetings  of  the  American  Surgical  Association.  In 
1897,  he  had  made  a  fleeting  visit  to  New  Orleans,  in  attendance  upon  the 
meeting  of  our  national  organization,  where,  contrary  to  his  custom,  he  had 
reluctantly  given  a  remarkable  demonstration  of  his  operation  for  hernia, 
at  our  Charity  Hospital ;  but  his  reserve  and  caution  in  making  new  acquain- 
tances, his  seeming  formality,  always  well  concealed  by  the  most  perfect 
urbanity,  made  him  rather  difficult  of  approach  and  kept  at  a  distance  men 
who,  fully  aware  of  his  great  worth  and  of  the  prestige  of  his  well  earned 
national  reputation,  were  eager  to  meet  him  but  made  no  advances,  owing 
to  the  impression  that  Dr.  Halsted  would  not  be  over-responsive  to  their 
attentions. 


xviii  WILLIAM  STEWAET  HALSTED 

In  1898  and  1899,  in  consequence  of  my  interest  in  regional  and  local 
anaesthesia,  I  came  into  a  closer  knowledge  of  the  pioneer  labors  of 
Dr.  Halsted,  which  gave  him  the  rightful  claim  to  the  discovery  of  neuro- 
regional  anaesthesia — the  so-called  "  conduction  anaesthesia  "  of  the  German 
writers — better  known  with  us  as  "nerve  blocking "  which,  thanks  to  his 
initiative  and  personal  experiments  upon  himself,  led  to  the  extraordinary 
developments  of  this  mode  of  abolishing  pain  that  we  have  all  witnessed 
with  amazement  in  the  last  few  years.  Not  only  did  he  clearly  and  unequivo- 
cally demonstrate  for  the  first  time  that  the  principle  of  nerve  blocking 
could  be  utilized  to  obtain  the  anaesthesia  of  the  peripheral  nerves  for  surgi- 
cal purposes — a  discovery  promptly  utilized  in  dental  and  oral  practice — 
but  he  went  a  step  further  and  demonstrated  that  the  blocking  of  the  spinal 
cord  with  anaesthetic  drugs  could  be  made  subservient  to  this  general 
principle. 

From  his  early  experiments  and  researches,  a  general  law  was  formu- 
lated, which  could  well  be  named  after  him,  "  Halsted's  Law,"  namely,  that 
the  infiltration  of  a  sectional  area  of  sensory  nerve  trunk  or  path,  with  an 
analgesic  substance,  was  equal  to  the  anaesthesia  of  its  peripheral  distribu- 
tion. This,  in  essence,  is  the  very  foundation  of  all  the  present  and  most 
useful  methods  of  regional  anaesthesia. 

He  also  anticipated  and  even  went  a  step  further  than  Schleich,  who  is 
credited  as  the  originator  of  the  principle  that  plain  isotonic  saline  solu- 
tions, Avhen  massively  infiltrated  into  the  tissues  so  as  to  produce  a  tense 
local  dropsy,  were  capable  of  producing  local  anaesthesia,  even  for  surgical 
purposes;  thereby  demonstrating  that  extremely  dilute  solutions  of  cocaine 
and  other  dangerous  anaesthetic  drugs  could  be  used  effectively  in  almost 
infinitesimal  dilutions,  thus  relieving  them  of  their  toxic  qualities. 

It  is  interesting  to  relate,  as  told  by  Cushing,  that  fifteen  years  later  when 
Cushing  rediscovered  the  principle  of  nerve  blocking  and  applied  it  success- 
fully in  operations  on  hernia,  publishing  his  well  known  paper  on  the  sub- 
ject, he  was  utterly  unaware  that  his  chief  had  ever  made  studies  on  cocaine 
of  any  sort — so  reticent  was  Dr.  Halsted  about  this  matter  and  so  little  did 
questions  of  priority  interest  him.1 

A  similar  illustration  of  his  indifference  to  mere  claims  of  priority  was 
repeated  only  a  year  ago,  1922,  when,  in  the  course  of  a  discussion  at  the 
American  Surgical  Association  of  a  paper  by  Dr.  Edward  Klopp,  of  Phila- 

1  It  is  only  quite  recently,  on  April  1,  1922,  barely  six  months  before  Dr.  Halsted's 
death,  that  the  fundamental  importance  and  significance  of  his  great  discoveries  in 
local  and  regional  analgesia  were  duly  recognized  by  the  American  National  Dental 
Association.  After  the  painstaking  investigation  of  a  committee  headed  by  the 
distinguished  dentist,  Dr.  C.  Edmund  Kells,  of  New  Orleans,  this  representative  body 


AN  APPRECIATION  xix 

delphia,  on  "  Refusion  or  Reinf usion  of  Blood  in  Haemorrhage  "  it  came  to 
light  that  Dr.  Halsted  had  frequently  practised  the  procedure  thirty  years 
previously  and  had  saved  a  number  of  lives  by  its  application  while  acting 

presented  him  with  the  beautifully  designed  gold  medal  and  gave  him  full  credit  as 
the  originator  of  the  method  of  neuroregional  anaesthesia  which  has  proven  of  such 
incalculable  service  in  oral  and  dental  surgery. 

The  following  extracts  from  a  letter  addressed  by  Dr.  Halsted  to  the  writer,  on 
April  3,  1922,  the  day  following  the  brilliant  and  enthusiastic  ovation  tendered  him 
by  the  National  and  Maryland  Dental  Associations,  are  quoted  to  show  how  thor- 
oughly human  Dr.  Halsted  was  and  how  sensitively  he  reacted  to  this  spontaneous 
and  most  genuine,  though  belated,  tribute  to  his  great  discovery. 

He  wrote :  "  The  Celebration,  as  Dr.  Kells  will  tell  you,  was  a  remarkable  success. 
I  am  so  thankful  to  have  lived  to  take  part  in  it.  Not  a  wink  of  sleep  did  I  get  during 
the  night  of  Saturday.  I  was  too  exhilarated  for  repose.  Once  before  in  my  life, 
I  was  kept  awake  by  great  happiness;  this  was  the  night  that  I  passed  successfully 
the  examination  for  Bellevue  Hospital  in  1876.  Here  it  was  in  contemplation  of  the 
future,  now  in  reflection  upon  the  good  fortune  that  led  to  our  friendship.  The  reaction 
from  this  great  joy  seems  to  be  setting  in  tonight  and  my  happiness  is  tinged  with 
regret  for  the  lost  opportunities,  for  the  time  wasted  from  loss  of  health,  etc." 

In  his  touching  allusion  to  "  our  friendship  "  with  special  reference  to  this  occasion 
he  had  in  mind  the  fact  that  I  had  been  instrumental,  without  his  knowledge,  in 
securing  complete  and  indisputable  evidence  of  his  right  to  priority  in  the  discovery 
of  regional  anaesthesia  "  nerve  blocking  " — as  applied  especially  to  dental  and  oral 
surgery,  and  had  established  his  historic  right  to  recognition  by  the  Dental  Associa- 
tions in  papers  published  long  before  I  had  known  him  personally. 

While  local  and  regional  analgesia  had  been  one  of  his  great  passions,  Dr.  Halsted 
did  not  overlook  the  progress  of  general  anaesthesia.  In  this  also  he  was  in  the  van 
of  progress;  for  on  February  17,  1910,  while  participating  in  a  discussion  at  the  New 
York  Academy  of  Medicine,  on  Meltzer  and  Auer's  method  of  intratracheal  ventila- 
tion in  its  application  to  intrathoracic  operations  for  purposes  of  artificial  respiration 
and  anaesthesia,  he  referred  to  his  own  experiments,  at  Hopkins,  with  differential 
pressure  in  pulmonary  and  intrapleural  operations  on  the  lower  animals,  and  inciden- 
tally gave  an  account  of  his  experience  with  a  mixture  of  nitrous  oxid,  carbon  dioxide 
and  oxygen,  which  he  has  been  using  very  successfully  for  one  year  in  his  clinic. 
In  closing  his  remarks  he  said  that  before  he  had  used  these  gases,  he  had  not  realized 
how  detrimental  the  use  of  ether  was  in  comparison.  {Med.  Record,  March  19,  1910, 
p.  511.)  Here  we  see  him  as  a  pioneer  in  a  new  field,  trying  and  investigating  a  com- 
bination of  anaesthetic  gases  at  a  time  when  gas-oxygen  sequence  and  gas-oxygen 
mixture  for  prolonged  surgical  operations  was  practically  unknown,  and  ether  was 
still  the  universal  anaesthetic  in  surgery. 

In  connection  with  the  Meltzer-Auer  method  of  intratracheal  ventilation  for  artificial 
respiration,  the  following  passage  from  a  personal  letter  addressed  to  me  by  Professor 
Halsted  on  July  10,  1921,  is  interesting:  "I  wish  I  could  have  heard  your  paper  on 
pneumothorax.  You  will,  I  trust,  favor  me  with  a  reprint.  Meltzer  and  Auer  antici- 
pated me  in  the  publication  of  the  insufflation  method.  Gatch,  my  assistant,  and  I 
had  been  working  for  some  time  along  the  same  lines,  but  not  knowing  of  Meltzer's 
work,  were  too  deliberate.  Meltzer  was  such  a  true  friend  to  me  that  I  would  not 
in  any  event,  have  tried  to  anticipate  him." 


xx  WILLIAM  STEWART  HALSTED 

as  surgeon  at  the  old  Chambers  Street  Hospital  in  New  York.  Credit  had 
been  given  Johartn  Thiess  of  Leipzig,  as  the  originator  of  this  method  of 
reinfusion  or  autotransfusion.  This  surgeon  had  published  his  experience 
in  1914  when  he  had  applied  it  for  the  relief  of  exsanguinated  patients  in 
ruptured  extrauterine  pregnancy;  but  Dr.  Halsted  had  clearly  antedated 
him  by  at  least  thirty-one  years,  as  will  be  seen  by  anyone  consulting  the 
files  of  the  Annals  of  Surgery  (vol.  ix,  pp.  7-21,  1884)  and  the  Proceedings 
of  the  New  York  Surgical  Society  of  November  13,  1883  (New  York  Medi- 
cal Journal,  1883,  vol.  xxxviii,  pp.  625-629),  in  which  are  described  his 
experiences  and  clinical  applications  of  the  principle  of  blood  "  refusion  " 
(as  he  termed  it)  in  the  treatment  of  illuminating  gas  poisoning.  After 
copious  blood-letting,  the  blood  of  the  patient  was  collected,  defibrinated 
and  thereby  sufficiently  aerated  to  deprive  it  of  its  toxic  properties.  It  was 
then  filtered  and  reinfused  into  the  radial  artery  of  the  same  patient,  thus 
administering  an  arterial  centripetal  infusion.  The  results  obtained  by  this 
procedure — suggested  to  Dr.  Halsted  by  reading  Hermann's  Physiology  and 
Hiitter's  advocacy  of  arterial  transfusion  in  preference  to  the  venous  route — 
were  remarkable.  Patients,  who  were  comatose,  would,  after  bleeding, 
promptly  become  conscious  and  even  quite  rational,  and  upon  the  reinfusion 
of  the  defibrinated  and  detoxicated  blood  would  recover  still  further.  The 
technique  of  refusion  in  haemorrhage,  as  practised  at  the  present  time,  is 
different  in  many  respects,  but  remains  essentially  the  same  in  principle  as 
that  first  applied  by  Halsted,  forty-three  years  ago.  And,  yet,  as  in  the  case 
of  the  discovery  of  neuroregional  anaesthesia,  it  would  have  remained  buried 
in  oblivion,  so  far  as  Dr.  Halsted  himself  was  concerned.3 

* 
*  * 
It  was  in  the  fall  of  1903,  a  little  over  twenty  years  ago,  fourteen  years 
after  I  had  known  Professor  Halsted  as  a  great  soulful  surgeon,  that  I  came 
to  know  him  for  the  first  time  by  personal  contact  and  under  circumstances 
which  revealed  the  still  greater  qualities  of  his  heart.  As  I  was  convalescing 
in  his  home,  I  learned  to  love  the  sound  of  his  cautious  footsteps  as  he 
approached  my  room  late  at  night,  to  assure  himself  of  my  comfort  and  to 

*  Two  remarkable  incidents  which  occurred  early  in  Dr.  Halsted's  career  are  recalled 
by  the  reference  to  his  original  method  of  blood  "  refusion."  The  first  is  the  saving 
of  his  sister's  life  when  exsanguinated,  seemingly  moribund  from  the  effects  of  post- 
partum haemorrhage.  He  arrived  at  the  critical  moment,  arrested  the  haemorrhage 
which  had  resisted  the  efforts  of  the  attending  obstetrician  and  immediately  revived 
her  by  transfusing  her  with  his  own  blood.  This  occurred  in  1881,  six  years  after  his 
graduation  in  medicine.  A  year  later  he  was  summoned  in  haste  to  his  mother's 
bedside  at  Albany  and  arrived  in  time  to  operate  at  2:  00  a.  m.,  and  save  her  life  by 
draining  an  empyema  of  the  gall-bladder  which  was  about  to  rupture,  and  extracting 
seven  gall-stones.  In  both  instances  the  ablest  surgeons  had  been  in  attendance. 
This  was  in  1882,  and  is  one  of  the  earliest  deliberately  planned  operations  for  gall- 


AN  APPKECIATION  xxi 

inquire  with  parental  solicitude  into  the  events  of  the  day.  He  would  sit  by 
my  bedside  and,  relaxing  after  the  arduous  work  of  the  day,  indulge  me 
with  his  commentaries  on  many  of  the  questions  and  problems  in  which  we 
were  mutually  interested.  He  often  reverted  to  his  postgraduate  days  in 
Leipzig,  Vienna,  Berne,  which  had  been  destined  to  exercise  such  a  pro- 
found influence  upon  his  career  as  a  teacher  and  operator.  That  he  was 
held  in  the  highest  esteem  in  Germany  is  evident  from  the  eagerness  with 
which  his  publications  were  sought  by  the  leading  German  surgical  journals 
and  societies,  and  from  the  fact  that  his  clinic  at  The  Johns  Hopkins  Hospital 
was  the  only  American  institution  included  in  the  list  of  the  great  clinics 
that  enrich  the  pages  of  that  leading  organ  of  German  surgical  thought, 
Bruns'  Beitrage  zur  Chirurgie.  He  had  already  been  elected  an  honorary 
fellow  of  the  Eoyal  College  of  Surgeons  of  England,  and  of  the  Eoyal  Col- 
lege of  Surgeons  of  Edinburgh,  of  the  Deutsche  Gesselschaft  fur  Chirurgie, 
and  of  that  exclusive  body,  the  Societe  de  Chirurgie  de  Paris — all  very 
highly  prized  and  coveted  honors,  which  he  duly  appreciated  but  to  which 
he  only  referred  in  the  most  modest  unpretentious  way,  and  merely  in  con- 
nection with  interesting  episodes  or  incidents  that  had  occurred  in  the 
course  of  his  visits  to  foreign  capitals.  His  critical  comments  on  surgical 
institutions  and  leaders  abroad,  as  compared  with  our  own,  were  most 
illuminating. 

It  is  quite  evident  that  all  his  honors  had  come  to  him  spontaneously,  and 
solely  through  his  own  merit.  Never  by  self-seeking,  nor  by  the  employ- 
ment of  subtle  diplomatic  agencies,  so  often  the  resort  of  men  of  lesser 
worth. 

He  often  referred  to  the  early  experiences  of  his  career,  when  he  had 
returned  from  Europe  full  of  enthusiasm,  fired  with  a  laudable  ambition 
to  improve  his  opportunities  for  the  expansion  of  his  active  mind  in  the 
promising  field  that  was  assured  him  in  New  York.  Throughout  these 
friendly  chats,  he  referred  to  his  achievements  in  New  York  only  as  reminis- 
cences, laying  no  stress  upon  the  prime  role  which  he  had  played  in  these 
epochal  discoveries.  In  connection  with  the  discovery  of  neuro-regional  an- 
aesthesia, he  casually  referred  to  a  major  operation,  which  he  had  performed 
in  the  winter  of  1884-1885  under  regional  anaesthesia,  and  in  which  he  had 
freed  the  cords  and  nerves  of  the  brachial  plexus  by  blocking  its  roots  in 
the  neck  with  cocaine  solution.  As  illustrating  his  enthusiasm  and  enter- 
prise in  testing  all  new  methods  that  appealed  to  his  investigating  mind, 

stones  in  this  country.  These  remarkable  incidents  will  no  doubt  receive  proper 
appreciation  in  his  biography,  as  they  reveal  not  only  Dr.  Halsted's  resolute  character, 
his  courage,  clear  vision  and  strong  convictions  in  matters  which  to  most  men  of 
his  time  were  still  hazy  and  practically  intangible.  They  also  show  that  in  matters 
of  surgical  knowledge  and  judgment  he  was  way  ahead  of  his  time. 


xxii  WILLIAM  STEWAKT  HALSTED 

this  operation  on  the  plexus  (which  I  do  not  believe  is  now  known  to  many) 
is  interesting,  as  it  was  performed  in  a  large  tent  which  he  had  built  and 
furnished  at  his  own  expense  on  the  grounds  of  Bellevue  Hospital,  having 
found  it  impossible  to  carry  out  antiseptic  precautions  in  the  general  amphi- 
theatre of  Bellevue,  where,  he  said,  "  Numerous  antagonistic  anti-Listerian 
surgeons  dominated  and  predominated." 

His  constant  and  affectionate  references  to  the  ability  and  skill  of  his 
younger  assistants,  whose  accomplishments  he  often  extolled  above  his  own, 
impressed  one  as  striking  evidence  of  his  wonderful  generosity  and 
liberality. 

I  cannot  recall  the  days  passed  at  Dr.  Halsted's  home  on  Eutaw  Place, 
without  investing  him  with  all  the  attributes  of  a  knight  of  the  profession, 
a  pure  and  high-minded  devotee  of  his  art,  the  modernized  replica  of  such 
an  one  as  Guy  de  Chauliac  described  nearly  six  centuries  ago : 

"  Bold  in  those  things  that  are  safe,  or  that  he  can  safeguard  by  his  own 
judgment  and  experience ;  fearful  in  those  that  are  dangerous ;  avoiding  all 
evil  methods  and  practices ;  tender  to  the  sick,  honorable  to  the  men  of  his 
profession ;  truthful,  wise  in  his  predictions ;  chaste,  sober,  pitiful,  merciful, 
not  covetous  nor  extortionate." 

Dr.  Halsted's  gentleness  and  kindness,  his  great  concern  for  suffering, 
his  minute  precautions  against  the  unnecessary  spilling  or  waste  of  blood, 
his  watchfulness  and  anxiety  about  the  fate  of  his  patients,  afford  one  of 
the  most  touching  and  beautiful  examples  of  the  humanity  and  the  humane 
qualities  of  the  real  surgeon.  There  are  many  still  who  would  interpret  a 
calm  and  unemotional  exterior  as  an  evidence  of  disregard  of  suffering  or 
indifference  to  human  life;  some,  who  believe  that  the  practice  of  surgery 
suppresses  in  the  hearts  of  those  who  exercise  it  the  gentler  qualities  of  sym- 
pathy and  finer  sensibility.  The  truth  is,  nothing  so  cultivates  the  noblest 
human  qualities,  nothing  exalts  more  the  sense  of  pity,  sympathy  and  char- 
ity, than  does  an  intimate  knowledge  of  the  causes  and  consequences  of  the 
processes  of  disease,  nothing  more  stimulates  tenderness  than  the  constant 
contact  with  suffering  and  distress,  by  those  whose  training  has  taught  them 
to  gauge  these  in  a  manner  far  more  subtle  and  just  than  is  given  to  the 
ordinary  well  meaning  but  purely  emotional  observer. 

These  reflections  apply  with  special  stress  when  the  surgeon  is  a  man  of 
the  type  of  Professor  Halsted;  a  man  of  gentle  breeding,  inherently  cour- 
teous, kind,  truthful,  and,  above  all,  exquisitely  sensitive  to  his  responsi- 
bilities. 


Twenty  years  have  elapsed  since  that  memorable  day,  when,  through  a 
fortuitous  circumstance,  I  became  the  fortunate  beneficiary  of  Dr.  Halsted's 


AN  APPRECIATION  xxiii 

skill,  and  through  his  skill  learned  the  full  measure  of  his  generous  heart. 
Time  has  only  confirmed  these  grateful  impressions.  As  the  years  have 
rolled  by,  they  have  each  come  laden  with  the  mellow  fruit  of  his  intellectual 
harvesting,  so  that  now  the  fruition  of  his  sowing  is  piled  mountain  high 
in  enduring  testimonial  to  his  greatness. 

Anyone,  who  has  attentively  followed  the  progress  of  surgery  in  our  coun- 
try during  the  three  decades  that  Professor  Halsted  has  presided  over  the 
surgical  activities  of  this  great  school,  finds  it  unnecessary  to  consult  the 
Index  Medicus  for  the  information  that  his  personal  labors  and  example 
have  left  an  indelible  impression  upon  the  history  of  surgery,  not  only  in 
America,  but  everywhere  where  the  language  of  surgery  is  spoken  and  taught. 
Even  if  time  allowed,  it  would  be  impossible,  in  the  most  cursory  way,  to 
review  or  mention  all  the  salient  contributions  catalogued  in  his  voluminous 
bibliography.  Fortunately  this  herculean  task  is  not  needed,  and  indeed 
would  prove  superfluous  in  these  sympathetic  and  congenial  surroundings. 
Every  surgeon  who  is  familiar  with  Dr.  Halsted's  scientific  accomplishments 
(and  who  is  not,  who  is  at  all  familiar  with  the  literature  of  his  profession  ?) 
must  admit  that  if  Dr.  Halsted  had  given  only  one  of  the  many  discoveries 
with  which  he  has  enriched  the  science  of  his  profession,  it  would  have  suf- 
ficed to  immortalize  his  name.  As  it  is,  he  has  left  a  legacy  that  would 
crown  the  lives  of  a  dozen  great,  but  lesser,  men ! 

That  I  may  not  be  suspected  of  the  partiality  with  which  friendship  so 
often  magnifies  our  estimate  of  the  merits  of  those  close  to  us  and  whom 
we  love,  allow  me  to  echo  a  voice  that  comes  to  us  from  the  far  away  but 
which  reaches  us  with  clear,  insistent  tones,  conveying  a  message  from 
across  seas,  which  is  in  gentle  harmony  with  the  spirit  that  animates  us  on 
this  occasion.  It  is  the  clarion  chant  of  Rene  Leriche,  surgeon  of  Lyons, 
France ;  himself,  one  of  the  foremost  and  most  brilliant  exponents  of  scien- 
tific surgery  of  his  own  country  and  of  the  present  generation.  A  tireless 
worker  and  searcher.  An  operator  of  the  highest  order.  Attracted  by  the 
world-wide  reputation  of  the  Departed  Master,  Leriche  visited  this  great 
center  of  surgical  learning.  He  came;  he  saw;  he  was  convinced.  Such  a 
man  is  well  entitled  to  speak  for  his  professional  brethren  at  home  and 
abroad,  who,  united  by  the  kinship  of  ideas,  ideals  and  high  resolves  for  the 
advancement  of  their  profession,  recognize  in  Professor  Halsted  an  inter- 
national leader. 

In  an  obituary,  which  appeared  in  the  Lyon  chirurgical,  of  October,  1922, 
Leriche  has  this  to  say  of  Dr.  Halsted's  passing : 

"  Though  it  is  not  in  the  traditions  of  this  journal  to  publish  obituary 
notices  of  eminent  surgeons  other  than  those  of  Lyonnese  birth,  we  have 
made  an  exception  in  Dr.  Halsted,  as  I  feel  that  the  traits  and  characteris- 


xxiv  WILLIAM  STEWART  HALSTED 

tics  of  this  good,  simple,  honest,  modest  man  of  kindly  approach  and  exqui- 
site courtesy,  who  was  one  of  the  greatest  surgeons  of  his  day,  should  be  per- 
manently recorded. 

"  It  is  not  only  because  he  was  one  of  the  greatest  surgeons  of  his  genera- 
tion that  I  think  it  a  duty  to  render  him  special  homage ;  not  even  because 
of  the  great  debt  which  surgery  owes  him,  more  especially  for  the  funda- 
mental principles  that  he  discovered, — as,  for  instance,  his  researches  which 
have  laid  the  foundation  for  regional  anaesthesia,  which  he  formulated  and 
demonstrated  in  1884 ;  his  introduction  of  the  rubber  glove  as  a  vital  element 
in  modern  aseptic  technic  in  1889, — two  rightful  claims  to  his  merit  which 
alone  entitled  him  one  of  the  benefactors  of  humanity;  but,  it  is  chiefly 
because  he  was  one  of  the  very  small  number  of  those  who  have  been  able 
to  enlarge  the  field  of  surgery,  to  elevate  its  standards  to  a  nobler  height, 
and  to  give  back  to  Surgery  more  than  he  had  received;  to  give  her  an 
impress  and  an  impulse  that  will  be  felt  for  years  to  come.  Others  may  have 
been  more  brilliant,  more  seductive,  perhaps,  more  impressive  to  the  passing 
visitor;  but  the  impressions  left  by  spectacular  operators  are  ephemeral, 
transient,  and  easily  erased;  because  generally  those  who  are  called  great 
operators  only  leave  their  imprint  upon  the  shifting  sands  of  time.  Halsted's 
performance  was  of  a  different  sort.  It  is  destined  to  endure  and  to  last  long 
after  him,  because  he  dealt  with  the  understanding  of  things;  because  he 
built  upon  the  very  rock  upon  which  the  foundations  of  surgery  rest,  and 
upon  which,  as  a  branch  of  the  healing  art,  it  is  based. 

"  As  an  operator,  Halsted,  like  Terrier  and  like  Kocher,  was  the  Father 
of  a  School  of  Surgery,  which  may  be  described  as  the  Surgery  of  Safety; 
of  a  technic  which  sacrificed  everything  to  the  immediate  and  future  suc- 
cess of  the  operation  and  the  welfare  of  the  patient.  He  put  in  force  the 
most  rigorous  asepsis  and  the  most  uncompromising  discipline  in  guarding 
the  tissues  from  insult,  by  neglecting  no  details,  no  matter  how  small,  that 
might  compromise  the  issue  and  the  thoroughness  and  finish  with  which  he 
carried  out  the  operative  act. 

"  Beginning  at  a  time  when  surgery  was  still  living  under  the  spell  of  the 
preanaesthetic  days,  when  rapidity  of  execution  was  given  the  highest  pre- 
mium, he  stood  firm  on  the  ground  that  the  nature  of  the  material  upon 
which  the  surgeon  exercised  his  handicraft  is  too  noble  and  too  precious  to 
be  insulted  with  impunity,  or  to  allow  even  the  smallest  living  particle  to 
be  wasted ;  that,  to  do  this  effectively,  the  surgeon  must  subordinate  bril- 
liancy and  rapidity  to  safety. 

"  I  have  elsewhere  related  what  Halsted  had  accomplished  in  this  direc- 
tion, and  I  need  not  rehearse  the  story  of  his  life  work,  but  I  will  recall  that 
from  this  point  of  view  all  the  surgeons  of  our  day,  who  are  his  pupils  with- 
out knowing  it,  owe  him  a  thought  of  gratitude. 

"  As  an  investigator,  Halsted  understood  surgery  as  an  experimental 
science,  aiming  as  his  objective  the  greater  and  deeper  knowledge  of  the  laws 
that  govern  physiological  and  pathological  life.  It  is  difficult  to  express  one's 
ideas  without  appearing  to  repeat  mere  truisms,  but  none  the  less,  I  say 
this  advisedly,  and  as  I  feel  it ;  the  surgeon  is  too  often  only  a  mere  techni- 
cian, a  man  who,  as  the  name  implies,  is  one  who  works  with  his  hands.  For 


AN  APPEECIATION  xxv 

such  a  man,  his  intellectual  exercise  is  chiefly  an  affair  of  comparing  his  own 
observations  with  other  recorded  or  published  precedents  and  from  this 
comparison  drawing  his  deductions.  This  is  mainly  a  critical  exercise,  but 
not  creative  work.  We  often  hear  the  surgeon  say,  '  It  is  my  impression,' 
'  I  believe/  '  I  feel,' '  It  appears  to  me.'  Earely  does  he  display  the  scientific 
spirit,  the  spirit  of  inquiry,  which  plunges  deep  beyond  the  surface  in  search 
for  causes.  He  may  even  pride  himself  in  being  purely  practical,  so  deeply 
impregnated  is  he  with  the  contingent  and  relative  character  of  his  art. 
None  the  less,  he  is  terribly  dogmatic  and  his  dogmatism,  which  is  the  con- 
tinuous outgrowth  of  temporary  impressions,  blinds  him  to  the  fact  that  he 
has  lost  his  intellectual  independence  and  has  become  the  slave  of  a  vicious 
habit  of  mind.  Halsted  saw  things  differently.  He  saw  a  pathological  and 
clinical  problem  everywhere  that  invited  investigation  and  that  he  made  the 
object  of  his  experimental  researches  which  he  carried  out  with  patience, 
painstaking  labor  and  with  all  the  discipline  of  a  Claude  Bernard.  After 
settling  on  his  problem,  he  thought  it  out  to  himself ;  he  looked  at  it  from 
every  angle,  but  first  objectively  as  a  physiologist,  then  as  a  clinician.  In 
speaking  with  him,  one  was  surprised  to  discover  all  that  he  had  sought  to 
verify  for  himself,  to  control  by  experiment,  to  see  clearly  where  the  facts 
were  leading  him,  long  before  he  arrived  at  conclusions.  On  the  other  hand, 
one  felt  suddenly,  almost  as  a  revelation,  what  a  huge  gap  there  was  in  the 
classical  methods  of  medical  training  and  education — methods  of  instruc- 
tion which  appeal  more  to  the  memory  than  to  reason  and  observation  and 
which,  in  consequence,  tend  to  waft  the  mind  of  the  learner  rather  towards 
the  knowledge  of  the  past  than  to  that  of  the  future. 

"And  then  one  understood  how  the  good  old  master,  of  almost  timid 
aspect,  had  remained  always  young  in  spirit ;  so  alert,  so  open  to  new  ideas ; 
so  inquisitive ;  so  investigative,  in  all  matters  that  were  beyond  the  common 
ken  and  that  required  thought.  He  seemed  always  ready  to  suggest  new 
researches,  urging  the  young  men  who  surrounded  him  ever  onward,  to 
explore  untrodden  paths  and  to  blaze  new  trails,  remaining  unto  the  end 
the  inspirer  and  the  incomparable  chief  of  a  band  of  exceptional  men." 

* 
*        * 

Allow  me  to  detain  you  for  a  brief  space  with  a  few  reflections,  suggested 
by  the  commentary,  occasionally  heard,  that  Dr.  Halsted  was  not  what  is 
popularly  described  as  a  "  brilliant  operator,"  a  statement  which  might  be 
interpreted  as  depreciatory  of  his  technical  abilities  by  those  who  are  un- 
familiar with  his  aims  as  a  surgeon  and  the  principles  that  governed  his 
operative  acts.  If  by  "  brilliant "  we  mean  the  surgeon  who  utilizes  his 
opportunities  to  dazzle  the  public  with  the  prodigies  of  his  skill,  who  listens 
for  the  plaudits  of  the  multitude  more  intently  than  he  does  to  the  mur- 
mured approval  of  his  conscience,  and  who  burns  his  incense  to  the  gods 
of  the  gallery,  then,  we  must  agree,  Dr.  Halsted  was  not  one  of  that  class. 
But,  what  do  we  mean  by  a  brilliant  operator  ?   In  the  sense  in  which  it  is 


xxvi  WILLIAM  STBWABT  HALSTED 

most  commonly  used,  brilliancy  is  a  quality  whose  chief  characteristic  is 
speed,  the  quickness  and  dexterity  with  which  an  operator  executes  and 
accomplishes  the  operative  act.  This  is  a  quality  in  which  our  forefathers 
excelled,  to  acquire  which  they  bent  all  their  energies,  and  in  which  they 
vastly  surpassed  us.  In  this  respect,  we,  the  surgeons  of  the  present  genera- 
tion, can  no  more  compare  our  performances  with  theirs  than  we  can  make 
comparison  between  the  speed  of  a  horse  car  and  that  of  a  twentieth  century 
limited  railroad  express.  But  when  we  consider  the  effects  of  a  collision 
between  horse  cars,  on  the  one  hand,  and  railroad  trains,  on  the  other, 
including  the  wreckage  that  follows  in  each  case,  we  may  form  some  idea 
of  the  relative  effects  of  speed  as  applied  in  the  cyclonic  operations  of  the 
older  surgery  and  the  calm  but  sure  and  safer  motions  of  the  surgery  of  the 
present.  Happily  for  us  and  for  humanity,  the  time  has  long  passed  when 
surgical  brilliancy  and  ability  could  be  gauged  by  the  clock,  or  when  the 
relative  merits  of  surgeons  could  be  estimated  by  the  rules  of  the  prize  ring 
or  the  authority  of  the  Marquess  of  Queensbury.  That  was  well  enough  in 
the  dim  days  of  antiquity,  in  the  days  of  Galen  and  Celsus,  when  limbs  of 
conscious  men  were  amputated  with  an  axe  or  a  guillotine :  or  in  much 
later  days,  when  a  Lisfranc,  a  Dieffenbach,  a  Lizars,  or  a  Liston,  could 
disarticulate  a  hip  in  five  minutes  or  less,  provided  that  in  the  flourish  of 
blades,  one  or  more  of  the  assistants  were  not  put  hors  de  combat  by  the 
lightning  maneuvers  of  the  operator;  or  that  one  could  say  of  a  modern 
master  what  was  said  of  Fergusson,  who,  in  lithotomy,  proceeded  with  such 
lightning  speed  and  skill  that  someone  advised  a  prospective  visitor  to  his 
clinic  to,  "  Look  out  sharp,  for  if  you  only  wink  you  will  miss  the  operation 
altogether ! " 

Then,  time  was  everything,  and  any  procedure  that  would  relieve  the 
patient  of  his  encumbrance  by  the  shortest  route  was  at  the  highest  pre- 
mium. Before  the  discovery  of  anaesthesia,  the  surgeon  had  to  be  a  man 
with  a  heart  of  steel  in  order  to  earn-  on  his  work  of  relief  in  an  atmos- 
phere reverberating  with  shrieks  and  yells,  lurid  with  blood,  and  laden  with 
the  germs  of  disease  and  death.  Then,  indeed,  he  was  best  surgeon  who 
could  slash  off  an  offending  limb  in  the  quickest  time.  Then,  indeed,  bril- 
liancy consisted  in  speed,  speed  at  any  cost,  and  the  price  of  speed  was  high. 
As  late  as  the  early  nineteenth  century,  the  death  rate  was  enormous,  full 
95  per  cent  and  over  for  the  hip ;  70  to  80  per  cent  for  the  thigh,  and  so  on. 
At  present,  by  the  modern  methods  of  safety,  it  has  fallen  to  an  insignifi- 
cant and  negligible  figure,  in  so  far  as  the  operative  act  is  concerned. 
However,  do  not  misunderstand  me  as  depreciating  the  quality  of  speed 
when  this  is  not  a  mere  race  for  a  record  but  is  the  legitimate  outcome  of 
dexterity,  knowledge,  system  and  method ;  the  outcome  of  long  experience 
and  faithful  practice  in  surgical  exercises. 


AN  APPKECIATION  xxvii 

But,  I  do  not  reckon  speed  as  brilliancy  when  displayed  chiefly,  if  not 
solely,  for  spectacular  effect ;  when  it  is  exhibited  at  the  expense  of  security, 
and  when  appraised  as  skill  it  is  rated  above  caution  and  judgment  at  the 
hazard  of  the  patient's  highest  interests. 

Let  us  not  forget  that  Surgery,  as  it  is  known  today,  was  a  terra  incognita 
to  the  most  daring  and  skillful  surgeons  of  scarcely  half  a  century  ago. 
Operations  that  are  now  a  part  of  the  daily  routine  of  every  well  established 
hospital  would  have  seemed  incredible  to  even  such  relatively  modern  mas- 
ters as  a  Mott,  a  Bigelow,  or  a  Gross  and  other  renowned  contemporaries  of 
this  period,  who  would  be  astounded  at  the  temerity  and  seeming  foolhardi- 
ness  of  their  successors. 

Professor  Halsted,  himself,  has  told  us  (Yale  Address,  1904)  that  "  in 
1876,  the  year  I  first  walked  the  wards  of  Bellevue  Hospital,  New  York,  the 
dawn  of  modern  surgery  in  America  had  hardly  begun."  The  discovery  of 
ether  was  not  so  old  as  to  have  obliterated  all  traces  of  the  surgical  rule, 
"  Tuto,  Cito  et  Jucunde,"  but  the  rapid  method  of  operating  was  slowly 
giving  place  to  safer,  more  conservative  and  deliberate  procedures.  In  fact, 
it  was  not  until  a  whole  decade  had  elapsed  after  the  introduction  of  anti- 
septic surgery  by  Lister  (1878  to  1888)  that  the  changed  conditions  wrought 
by  anaesthesia,  antisepsis  and  asepsis  were  actually  realized  by  the  mass  of 
the  profession.  It  was  only  then  that  the  systematic  invasion  of  the  great 
body  cavities  began  and  when  the  pelvis,  the  abdomen,  the  thorax,  and  the 
cranium  gradually  surrendered  their  contents  and  became  amenable  to  the 
laws  of  surgery. 

With  anaesthesia  and  asepsis  as  the  master  keys,  experimental  surgery 
received  a  new  impetus  and  the  horizon  of  surgery  rapidly  expanded. 
Eoentgen's  discovery  of  the  x-rays  then  came  in  1895-'96  to  inaugurate 
a  new  epoch  in  surgery  and,  by  illuminating  the  body,  incredibly  multiplied 
the  indications  for  surgical  intervention.  The  rays  and  the  collaboration 
of  the  physiological,  biochemical,  bacteriological  and  pathological  labora- 
tories have  all  combined  to  so  transform  the  entire  face  of  surgery  that  it  is 
no  longer  recognizable  in  the  light  of  its  ancient  portraitures. 

The  number  of  operations  has  not  only  multiplied  s  but  new  operations 
have  been  added  and  are  being  devised  which  could  not  have  been  attempted 

3  In  his  previously  mentioned  Yale  Address,  1904,  on  The  Training  of  the  Surgeon, 
Professor  Halsted,  in  drawing  a  parallel  between  the  old  and  the  new  surgery,  called 
attention  to  the  small  number  of  operations  performed  fifteen  years  before  the  date 
of  his  address — that  is,  thirts'-four  years  ago — and  their  progressive  and  enormous 
increase  ever  since  that  time.  He  quoted  the  pre-Listerian  experience  of  Billroth, 
Thiersch  and  v.  Mikulicz  to  show  what  comparatively  little  operating  was  done  in 
the  great  hospital  centers  of  Austria  during  the  forbidding  days  of  sepsis  and  which 
subsequently,  after  Lister,   became  the  theatre  of  the  greatest  surgical  activity.   In 


xxviii  WILLIAM  STEWART  HALSTED 

in  the  pre-Listerian  period  and  which  were  unthinkable  and  entirely  beyond 
the  conception  of  the  older  operators.  Again,  we  should  remember  that 
many  of  the  most  difficult  and  dangerous  operations,  made  possible  through 
the  advances  of  contemporary  surgery,  are  still  only  made  safe  by  the  exer- 
cise of  the  greatest  caution  coupled  with  most  consummate  skill. 

Such  undertakings  consume  time  and,  if  speed  is  to  be  the  criterion  of 
brilliancy,  the  surgeon  who  performs  these  operations — no  matter  how  suc- 
cessfully— can  never  be  called  "  brilliant."  And  it  is  precisely  this  class  of 
cases  in  which  Professor  Halsted  was  engaged ! 

According  to  my  understanding,  brilliancy  in  surgery  lies  more  in  the 
results  of  the  surgeon's  intervention  than  in  the  immediate  act.  To  my 
mind  he  is  the  most  brilliant  surgeon,  who,  in  equality  of  circumstances, 
saves  or  prolongs  the  greatest  number  of  lives  and  who  restores  his  patients 
to  health  in  the  shortest  number  of  days. 

The  brilliancy  of  the  operator  should  not  be  appraised  by  the  time  he  con- 
sumes in  the  performance  of  an  operation,  but  by  the  effect  that  follows  its 
achievement;  not  in  the  mere  recovery  of  the  patient  from  the  immediate 
operative  act,  but  in  the  way  in  which  he  recuperates ;  in  the  length  of  time 
required  for  his  recovery ;  in  the  period  demanded  to  restore  him  to  useful- 
ness, and,  above  all,  in  the  permanency  of  the  cure  which  it  accomplishes. 

It  is  in  this  manner  that  I  would  rate  and  compare  the  brilliancy  of  sur- 
geons, and  it  is  from  this  viewpoint  that  Halsted  is  considered  one  of  the 
most  brilliant  and  greatest  surgeons  of  his  time.  It  is  the  sort  of  brilliancy 

1900,  v.  Mikulicz  wrote  him  from  Breslau:  "When  I  was  a  student  in  Vienna,  there 
were  days,  particularly  in  winter,  when  not  a  single  operation  occurred  in  the  Univer- 
sity Clinic,  so  scarce  was  the  operative  material."  Quoting  the  statistics  of  the 
Massachusetts  General  Hospital,  he  states  "  that  in  the  entire  decennium  prior  to 
the  discovery  of  anaesthesia,  only  385  operations  were  performed  in  the  hospital — 
an  average  of  38.5  operations  a  year.  In  the  first  decade  subsequent  to  the  employment 
of  ether,  1893  operations  were  performed — an  average  of  189  per  year.  In  the  decade 
preceding  Lister's  visit  to  this  country  (1876),  from  1868  to  1878  there  were  7696 
operations.  In  the  next  decade  only  10,118  operations  were  performed,  but  from  1894 
to  1904,  there  were  24,270.  In  the  single  year  1903,  over  3000  operations  were  per- 
formed in  the  same  hospital."  The  Boston  City,  Roosevelt,  and  New  York  Hospital 
showed  an  increase  in  similar  proportion,  and  this  experience  is  repeated  all  over  the 
world.  The  Charity  Hospital  of  New  Orleans,  an  institution  which  dates  its  existence 
to  1832,  shows  a  record  of  only  172  operations  in  5309  admissions  during  the  year  1881, 
or  a  little  over  3.2  per  cent  of  the  total  patients  admitted,  and  of  these,  72  were 
amputations,  23  incisions  for  abscess,  18  extractions  of  bullets.  One  single  laparotomy. 
In  comparison,  we  find  that  in  1923,  42  years  later,  in  a  total  of  20,565  admissions, 
there  were  16,405  operations,  an  increase  of  79.7  per  cent!  Practically  80  per  cent  of 
the  patients  admitted  in  1923  had  furnished  indications  for  surgical  in tervent ion ! 
In  other  words,  the  treatment  of  disease  in  the  hospital,  which  in  1881  had  been  a 
little  over  96  per  cent  medical  or  pharmacal,  in  1923  became  80  per  cent  surgical. 


AN  APPRECIATION  xxix 

at  which  he  aimed  and  with  which  he  sought  to  imbue  his  pupils  through  his 
teachings  and  example.  It  is  the  sort  of  brilliancy  for  which  every  conscien- 
tious surgeon — who  places  his  patient's  welfare  and  the  good  repute  of  his 
profession  above  the  vanity  of  his  own  flesh,  should  strive. 

* 
*        * 

It  has  been  said  that  Dr.  Halsted  leaned  more  to  the  Science  than  to  the 
Art  of  Surgery.  This  no  doubt,  so  far  as  his  natural  inclinations  were  con- 
cerned, is  true ;  but  it  is  difficult  to  decide  which  of  the  two  he  benefited  the 
more.  When  we  consider  what  he  did  for  Surgery  as  a  craft  and  compare  the 
technic  of  Surgery  as  he  found  it  when  he  made  his  first  appearance  in  the 
surgical  arena  scarcely  more  than  forty  years  ago,  and  how  he  left  it  at  his 
death;  when  we  consider  what  he  did  for  the  three  fundamentals  of  Sur- 
gery— haemostasis,  anaesthesia  and  asepsis,  in  each  of  which  he  was  not  only 
a  pioneer  but  an  innovator,  whose  discoveries  have,  in  many  ways,  trans- 
formed the  entire  face  of  the  handicraft  of  Surgery,  we  have,  indeed,  reason 
to  pause  before  expressing  judgment.4 

Need  I  cite  examples  to  prove  Professor  Halsted's  inventiveness  and  his 
influence  in  remodeling  and  recasting  the  older  technic  of  Surgery  as  he 

*  Those  who  have  not  been  privileged  to  see  Dr.  Halsted  actually  at  work  in  his 
clinic  may  be  able  to  gain  an  insight  into  his  qualities  as  a  technician  by  reading  his 
paper,  admirably  illustrated  by  Broedel,  in  the  Journal  of  the  American  Medical  Asso- 
ciation for  April  12,  1913.  In  this  paper,  Dr.  Halsted  gives  a  most  interesting  account 
of  the  several  methods  which  were  peculiar  to  his  clinic  and  which  he  originated.  In 
this  he  gives  convincing  reasons  for  his  preference  for  fine  silk  over  catgut,  and  his 
results  amply  justify  this  preference.  The  history  of  the  rubber  glove  as  introduced 
by  him  in  1890,  now  universally  recognized  as  the  most  important  adjunct  in  the 
practice  of  surgical  asepsis,  the  "boiled  hand";  his  use  of  gutta  percha  tissue  for  the 
protection  of  granulating  wounds  and  for  the  prevention  of  adhesion  of  dressings  and 
drains  to  the  tissues  (the  present  cigarette  and  cigar  drains,  so  generally  used,  are 
of  his  making),  and  the  use  of  silver  foil  and  a  number  of  ingenious  and  original 
modes  of  suture,  are  all  described  in  Dr.  Halsted's  inimitable  style.  His  use  of  fine 
straight  cambric  and  milliner's  needles,  split-eyed,  which  were  kept  threaded  with 
fine  silk  in  long  rows  on  sterile  towels  ready  for  immediate  use,  was  a  distinct 
peculiarity  of  his  clinic.  In  this  connection,  Dr.  Adrian  S.  Taylor,  Professor  of 
Surgery  at  the  Medical  College  of  Pekin,  has  contributed  a  paper  (China  Med.  Jour., 
xxxv,  September  5,  1921),  which  will  prove  interesting  to  those  who  desire  a  detailed 
account  of  Dr.  Halsted's  methods,  especially  in  the  use  of  silk  in  surgery,  as  they 
are  now  practised  by  one  of  his  most  successful  followers  in  the  far  East. 

Garrison  in  his  History  of  Medicine  (1913,  p.  264)  admirably  sums  up  Professor 
Halsted's  accomplishments  as  a  technician  in  the  treatment  of  surgical  wounds: 
"  Quietly  and  unobtrusively,  Halsted  has  taught  the  perfect  healing  of  wounds  which 
has  been  nowhere  more  beautifully  illustrated  than  in  his  clinic." 


xxx  WILLIAM  STEWAET  HALSTED 

found  it,  and  how  much  he  did  to  elevate  it  to  the  present  marvelous  state 
of  efficiency?  But  if  this  is  what  he  did  to  improve  the  methods  that  are 
fundamental  and  common  to  all  modern  operations,  how  can  we  question 
his  profound  interest  in  the  art  of  surgery  in  the  face  of  the  evidence  that  he 
has  given  us  of  his  perpetual  concern  in  improving  and  perfecting  the  art 
as  applied  to  more  complex  and  major  operative  problems?  Need  I  recall 
what  he  did  when  he  revolutionized  the  surgical  treatment  of  cancer  of  the 
breast  scarcely  a  quarter  of  a  century  ago  ?  Did  he  not  show  then,  by  the 
thoroughness  of  his  methods,  that  the  older  technic  of  the  operation  could 
be  so  greatly  improved  that  the  percentage  of  local  recurrences — whirh  had 
up  to  that  time  ranged  between  59  per  cent  (Volkmann)  and  85  per  cent 
(Billroth) — had  dropped  in  his  hands  to  the  low  figure  of  6  per  cent,  and  if 
the  regional  recurrences,  away  from  the  field  of  operation,  were  included,  the 
combined  total  of  local  and  regional  recurrence,  after  three  years'  observa- 
tion, did  not  exceed  22  per  cent ! 

The  publication  of  Professor  Halsted's  first  paper  in  1895,  which  de- 
scribed the  details  of  his  technic  and  which  showed  the  results  that  he  had 
obtained  by  his  method  since  1889,  brought  with  it  a  new  message  of  hope 
for  the  victims  of  cancer  and  stirred  the  surgeons  of  the  world  with  renewed 
ardor  in  the  pursuit  of  this  implacable  disease.  His  results,  as  first  pub- 
lished, clearly  show  that  the  old  traditional  saying,  "  Cancer  of  the  breast 
is  operated  upon,  but  not  cured,"  was  erroneous  and  that  by  operation  the 
disease  could  be  positively  eradicated  from  its  original  focus  of  invasion. 
In  other  words,  the  doctrine  that  cancer  is  primarily  a  local  disease  and  can 
be  permanently  rooted  out,  if  only  attacked  before  it  has  migrated  to  inac- 
cessible localities,  was  now  proven  to  be  true  far  more  conclusively  than  ever 
before.  But  even  more,  his  results  showed  that  when  it  had  advanced  to  what 
were  usually  regarded  as  its  impregnable  intrenchments,  the  apex  of  the 
armpit  and  the  neck,  there  was  still  hope  of  cure,  if  the  operation  was 
thoroughly  performed,  as  he  did  it.  The  result  of  Dr.  Halsted's  work  was 
that  he  synthetized  the  best  points  in  the  technics  that  had  been  suggested 
by  the  most  advanced  workers  and  he  added  new  principles  and  procedures 
which  contributed  to  the  thoroughness  of  the  extirpation.  It  was  in  the 
completeness  of  his  method  that  he  achieved  a  success  which  set  a  new  pace 
in  the  progress  of  breast  surgery,  and  established  a  standard  of  efficiency 
which  had  no  precedent  in  the  history  of  this  malignant  disease.' 

•In  an  admirable  study  of  "Cancer  of  the  Breast,"  published  in  Paris  in  1913, 
Baumgartner  thus  refers  to  Dr.  Halsted's  work: 

"By  combining  and  selecting  the  best  suggestions  offered  by  the  most  advanced 
operators  [and  adding  many  new  and  important  details  of  his  own]  the  American 
surgeon,  Halsted,  elaborated  a  surgical  technic  which  gave  a  powerful  impulse  to 


AN  APPKECIATION  xxxi 

There  are  many  of  us  who  recall  "  an  amputation  "  of  the  breast  for 
cancer,  as  it  was  classically  performed  in  the  late  seventies  and  early  eighties. 
The  operation  was  then  a  mere  mammectomy,  performed  in  fifteen  or  twenty 
minutes,  or  less,  with  a  few  rapid  and  sweeping  strokes  of  the  knife.  It  was 
a  quick,  "  brilliant "  but  bloody  affair,  in  which  the  diseased  mamma  and 
underlying  fascia  were  removed,  with  here  and  there  an  obviously  diseased 
axillary  gland.  There  was  no  effort  to  remove  the  breast  and  tributary  areas 
in  block  dissection,  or  systematically  to  pursue  or  ferret  out  the  disease  in  all 
its  known  hiding  places  or  routes  of  travel.  The  wounds  were  usually  easily 
closed  as  there  was  ample  skin  left  to  cover  the  incision  completely  without 
leaving  bare  surfaces. 

Then  the  operation  was  performed  chiefly  for  palliative  effect — only  with 
the  hope  of  prolonging  life,  but  not  for  cure.  At  best,  the  prolongation  of 
life  after  operation  was  short.  Sir  James  Paget,  in  an  early  publication, 
estimated  this  gain  of  life  at  four  months.  In  a  later  paper,  he  extended  the 
average  postoperative  expectation  of  life  to  twelve  months.  Other  observers 
of  the  same  period  estimated  it  at  ten  months  (Gross),  thirteen  months 
(Morrant  Baker),  twenty-two  months  (W.  E.  Williams),  thirty-one  months 
(Sibley).  Quite  often,  the  disease  recurred  in  the  wound  before  it  had  time 
to  heal.  Some  surgeons  of  the  greatest  experience  (such  as  Agnew)  frankly 
admitted  that  they  had  never  been  able  to  cure  a  cancer  of  the  breast  by 
operation  or  by  other  means.  Many  surgeons  did  not  share  in  these  extremely 
pessimistic  views  and  there  were  individual  groups  of  statistics  which  showed 
the  error  of  this  conclusion.  In  fact,  many  patients  survived  not  only  three 
years  without  recurrence  (which  Volkmann  had  proclaimed  as  a  test  of 
"cure  ")  but  five  and  more  years.  These  results,  however,  were  exceptional 
and  it  was  only  after  Halsted  had  enunciated  the  principles  upon  which  his 
operation  was  based  and  after  its  feasibility  had  been  demonstrated  that  the 
number  of  cures  of  three,  four,  five  years  and  much  greater  duration  multi- 
plied in  all  the  clinics  of  the  world  until  now  they  have  ceased  to  be  a  novelty 
and  can  no  longer  be  counted. 

While  the  cure  of  cancer  in  the  breast  and  elsewhere  is  dependent  upon 
innumerable  factors  entirely  unconcerned  with  mere  surgical  technic  and 
still  remains  a  problem  which  awaits  solution  and  intensely  preoccupies  the 
minds  of  all  surgeons,  the  fact  remains  that,  in  spite  of  the  great  gains  that 
in  recent  years  have  been  made  in  its  treatment  by  the  acquisition  of  radium 

a  more  radical  and  extensive  extirpation  of  cancer  of  the  breast.  The  operation 
he  devised  was  quickly  adopted,  wholly  or  with  variations,  by  the  majority  of  surgeons 

the  world  over Halsted's  operation,  or  any  other  that  approaches  it,  which 

is  based  upon  the  principles  that  govern  it,  is  amply  justified  by  its  [superior]  results, 
as  shown  by  all  published  statistics."  (A.  Baumgartner,  Maladies  de  la  mamelle. 
Nouveau  Traite  de  Chirurgie,  Le  Dentu-Delbet,  1913,  xxlii,  270.) 


xxxii  WILLIAM  STEWART  HALSTED 

and  x-ray  therapy,  the  only  hope  for  a  victim  of  cancer  of  the  breast  lies  in 
the  early  and  thorough  extirpation  of  the  disease  by  the  knife,  in  the  way 
planned  and  carried  out  by  Halsted. 

No  one  who  has  been  privileged  to  see  Dr.  Halsted  at  work  on  a  cancer 
of  the  breast,  especially  during  the  period  between  1895  and  1908,  when 
his  publications  had  attracted  many  visitors  to  his  clinics  to  study  his  meth- 
ods, could  fail  to  recognize  the  reason  for  his  extraordinary  success.  Deeply 
interested  in  his  work  and  absorbed  in  all  its  details,  whether  operating 
himself  or  directing  his  staff  of  well  trained  and  brilliant  assistants,  his 
delicate  but  far  reaching  dissections,  by  which  he  pursued  the  disease  relent- 
lessly, without  regard  to  esthetic  effect  or  plastic  union;  his  minute  and 
almost  fastidious  precautions  against  infection  and  haemorrhage,  controlling 
the  smallest  bleeding  point  so  that  the  total  blood  loss  throughout  the  opera- 
tion was'  negligible ;  his  skill  and  nicety  in  covering  large  skin  defects  with 
autogenic  skin  grafts  in  a  way  that  has  scarcely  been  equalled  and  has  never 
been  excelled,  and  his  final  dressing  of  the  wound,  covering  it  with  silver 
foil  and  with  immobilizing  plaster  dressing,  gave  the  impression  to  the 
onlooker  that  he  was  seeing  the  performance  of  an  artist  close  akin  to  the 
patient  and  minute  labor  of  a  Venetian  or  Florentine  intaglio  cutter  or  a 
master  worker  in  mosaic.  Yet  this  task,  which  with  all  its  discipline  and 
method  often  consumed  two  and  three  hours,  was  practically  shockless  and 
bloodless  and  was  followed  almost  invariably  by  recovery. 

In  May,  1907,  he  reported  to  the  American  Surgical  Association,  232 
cases  of  cancer  of  the  breast  operated  upon  in  The  Johns  Hopkins  Hospital 
by  his  method,  with  a  total  postoperative  mortality  at  the  hospital  of  1.7  per 
cent!  Of  the  total  number,  89  patients  (42.3  per  cent  of  210  traced  cases 
and  38.3  per  cent  of  232)  were  living,  free  from  recurrence  and  apparently 
cured,  three  to  five  years  after  the  operation." 

"Dr.  Bloodgood,  to  whom  Dr.  Halsted  often  "expressed  his  obligation  for  his 
efficiency  and  inexhaustible  zeal  in  collecting  the  statistics  of  his  operation,  year  after 
year,  for  so  many  years  "  further  elaborated  (in  1908)  the  statistics  of  his  Chief  as 
follows: 

"  The  statistics  in  Halsted's  clinic  up  to  the  present  time  show  among  210  cases,  in 
which  three  years  and  more  have  passed  since  the  operation,  that  42  per  cent  are 
apparently  well.  If  we  consider  the  cases  in  which  the  axillary  glands,  studied  micro- 
scopically, showed  no  evidence  of  metastasis,  61,  or  85  per  cent,  are  well.  In  cases 
in  which  the  axillary  glands  showed  metastasis  (110),  30  per  cent  recovered,  free 
from  recurrence  for  three  years.  When  the  glands  in  the  neck  showed  metastasis  (40 
cases),  only  10  per  cent  remained  well  for  three  years. 

"In  all  of  these  groups,  metastasis  has  been  observed  after  an  interval  of  three 
years  of  apparent  cure.  Such  late  metastases  may  take  place  up  to  eight  years  after 
operation.  Excluding  these  case  of  late  recurrence,  the  number  of  definitely  cured 
in  these  three  groups  is  reduced  to  75,  25,  and  7  per  cent,  respectively,  or  for  all  cases 
together,  35  per  cent."   (Amer.  Jour.  Med.  Sciences,  February,  1908.) 


AN  APPRECIATION  xxxiii 

Anyone  seeing  Dr.  Halsted  at  work  was  impressed  with  his  "  capacity  for 
taking  infinite  pains."  When  he  had  finished  his  task,  the  departing  visitor 
realized  that  Surgery,  in  his  hands,  had  made  her  supreme  effort  to  save  the 
victims  of  cancer  of  the  breast. 

The  same  interest,  originality  and  practical  value  is  displayed  in  the  technic 
which  he  evolved  for  skin  grafting,  for  the  suture  of  wounds,  for  the  radical 
cure  of  hernia,  for  the  resection  and  suture  of  the  intestines,  for  the  drainage 
and  suture  of  the  common  bile-duct  (at  a  time  when  most  men  were  limiting 
their  interventions  to  the  gall-bladder  and  the  cystic  duct 7).  His  operation 
on  the  thyroid  for  the  cure  of  goiter  remains  today  a  triumph  of  surgical  tech- 
nic. His  most  delicate  and  highly  anatomical  procedure  of  the  ligation  of  the 
inferior  thyroid  arteries  which,  in  spite  of  its  superiority,  few  men  have 
adopted,  because  the  upper  bipolar  ligations  are  so  much  easier.  His  success 
in  the  ligation  of  the  great  and  most  dangerous  arteries  (aorta,  innominate, 
subclavian,  carotid,  iliac).  His  ingenious  device  for  the  partial  and  progres- 
sive occlusion  of  the  aorta  and  other  great  vessels  in  the  cure  of  aneurism,5 

1  In  February,  1898,  Dr.  Halsted  performed  the  first  recorded  and  successful  opera- 
tion for  a  primary  carcinoma  of  the  papilla  of  Vater.  The  patient  was  a  woman 
sixty  years  old.  In  this  operation,  probably  the  most  difficult  and  dangerous  in  hepatic 
and  intestinal  surgery,  he  excised  part  of  the  duodenum  (nearly  its  entire  circum- 
ference) pancreas,  common  bile  duct  and  pancreatic  duct,  in  order  to  give  the  little 
growth,  no  larger  than  a  pea,  a  wide  berth.  After  the  excision  of  the  tumor,  the 
operation  was  completed  by  a  circular  suture  of  the  duodenum  and  transplantation 
of  the  common  duct  and  pancreatic  duct  ( Wirsung)  into  the  line  of  suture.  Two 
months  later  he  supplemented  the  operation  by  creating  an  anastomosis  between 
the  gall-bladder,  cystic  duct  and  duodenum  (cholecystduodenostomy).  The  patient 
recovered  fully  from  the  operation,  but  finally  succumbed  months  after  to  a  recur- 
rence of  the  cancer  in  the  pancreas  and  the  cystic  duct. 

This,  at  that  time,  a  unique  case,  was  reported  together  with  a  number  of  other 
remarkable  operations  in  his  "  Contribution  to  the  Surgery  of  the  Bile  Passages, 
Especially  to  the  Common  Bile  Duct,"  read  at  the  Suffolk  District  Medical  Society, 
Boston,  May  3,  1889  (Johns  tfopkins  Hosp.  Bull,  January,  1890) . 

8  Dr.  Halsted  was  the  first  surgeon  to  ligate  the  left  subclavian  in  its  first  division 
successfully  (May  10,  1892).  He  again  performed  the  same  ligation  (intrathoracic) 
successfully,  on  April  26,  1918.  In  this  case  (a  huge  subclavian  aneurism),  he  also 
ligated  simultaneously  the  left  carotid,  ligating  both  vessels  near  their  aortic  origin. 
This  is  probably  the  largest  subclavian  aneurism  ever  operated  upon.  Two  years 
after  the  ligation  he  excised  the  sac,  which  had  remained  and  was  beginning  to 
relapse — also  with  complete  success. 

He  had  ligated  the  subclavian,  in  all,  six  times  for  aneurism,  including  two  ligations 
of  the  first  division  of  the  left  subclavian,  followed  in  both  instances  by  a  secondary 
extirpation  of  the  sac.  "  The  patients  all  recovered  ideally  without  gangrene  or 
added  loss  of  function;  the  wounds  all  closed  without  drain,  healed  per  primam, 


xxxiv  WILLIAM  STEWART  HALSTED 

all  of  these  are  living,  palpable  testimonials  of  his  love  of  the  art  as  well  as 
the  science  of  his  profession.9 

In  every  region  of  the  body,  in  addition  to  the  extremities,  and  in  every 
advance  that  has  marked  the  progress  of  surgery  in  the  last  thirty  years,  we 
find  the  impress  of  his  hand  and  the  reflex  of  his  brain.  In  the  abdomen,  in 
the  thorax,  in  the  neck,  in  the  extremities,  are  stamped  the  indelible  marks 
of  his  passage,  always  moving  onward  in  search  of  new  discoveries  and  new 
conquests. 

and,  in  all,  the  aneurism  was  cured  "  (Ligation  of  the  Left  Subclavian,  loc.  cit.,  p.  15). 
He  also  ligated  the  innominate  five  times,  all  the  patients  recovering. 

He  was  the  first  to  occlude  successfully  the  thoracic  aorta  for  high  abdominal 
aneurism  with  a  partially  occluding  aluminum  band  (December  18,  1906). 

The  thorax  was  opened  and  the  aorta  exposed  under  positive  pressure  with  an 
apparatus  devised  b}'  his  assistants,  Follis  and  Fisher,  and  he  successfully  applied  the 
band  7  cm.  above  the  diaphragm.  Twenty-three  days  later,  he  applied  another 
aluminum  band  to  the  abdominal  aorta  of  the  same  patient,  distal  to  the  aneurism 
just  below  the  inferior  mesenteric  artery.  The  patient  survived  eighteen  days  after 
the  second  operation.  In  another  case  he  again  constricted  the  abdominal  aorta  with 
an  aluminum  band  on  February  23,  1909,  for  an  enormous  aneurism  of  this  vessel. 
The  band  was  applied  above  (cardiac  side  of)  the  renal  arteries.  The  patient  suc- 
cumbed on  the  forty-first  day  from  infection  of  the  aneurismal  sac. 

In  the  two  operations  on  the  aorta  performed  by  Dr.  Halsted,  the  fatal  termination 
was  due  in  each  case  to  unavoidable  complications,  but  not  to  defects  in  the  technic. 

9  Dr.  Halsted's  deep  interest  in  matters  of  pure  technic  remained  undiminished 
to  the  very  last.  His  paper  on  "  Blind  End  Circular  Suture  of  the  Intestines,  Closed 
Ends  Abutted  and  the  Double  Diaphragm  again  Punctured  with  a  Knife  Introduced 
Per  Rectum,"  was  published  in  the  Annals  of  Surgery  for  March,  1922,  six  months 
before  his  death  (September  7,  1922).  Of  this  procedure  he  wrote  me  in  a  personal 
letter  (August  24,  1921):  "A  few  days  ago  I  sent  you  a  package  of  photographs 
made  by  Max  Broedel,  to  illustrate  a  clean  and  very  simple  method  of  making  an 
end  to  end  intestinal  suture  which  I  worked  out  last  winter.  This  operation  was 
performed  upon  46  to  48  dogs  (large  intestine)  by  others  as  well  as  myself  (Reichert, 
Holman,  Mont  Reid)  and  without  fatality.  By  no  other  method  have  I  obtained 
such  ideal  results.  To  test  the  relative  merits  of  the  various  methods  of  suture  one 
should  make  an  early  examination  of  the  peritonaeal  cavity  twelve,  twenty-four,  and 
forty-eight  hours  after  the  operation.  Only  by  these  early  examinations  can  we  get 
an  idea  of  the  reaction  and  of  the  part  played  by  Nature  in  overcoming  the  errors 
and  bad  methods  of  the  surgeon." 

This  contribution  and  his  paper  on  the  "  Replantation  of  Entire  Limbs  Without 
Suture  of  the  Vessels  "  which  appeared  in  the  Transactions  of  the  American  Surgical 
Association  for  1922,  and  in  the  Proceedings  of  the  National  Academy  of  Science 
in  July,  1922,  are  the  last  contributions  which  he  gave  to  the  Scientific  world,  and  it 
is  fitting  that  these  two  papers  which  were  typical  of  his  attitude  of  mind  and  his 
habitual  mode  of  approaching  surgical  problems  should  have  appeared  almost  simul- 
taneously at  the  close  of  his  career,  so  true  were  they  to  his  two  paramount  interests 
in  his  professional  life,  the  culture  of  Surgical  Art  guided  and  controlled  by  Experi- 
mental Science. 


AN"  APPRECIATION  xxxv 

In  the  surgery  of  the  hrain  and  nervous  system,  in  which  his  literary 
contributions  figure  less  prominently,  it  is  none  the  less  Ms  technic,  Ms 
methods  and  doctrinal  ideas  of  thoroughness,  scrupulous  asepsis,  absolute 
haemostasis,  delicate  handling  of  the  tissues,  avoidance  of  gross  material,  and 
artistic  finish  in  the  final  closure  and  dressing  of  his  wound,  that  is  reflected 
in  the  work  of  his  gifted  pupils,  Cushing,  Heuer,  and  Dandy,  to  whom,  in 
succession,  he  intrusted  and  virtually  relegated  the  development  and  teach- 
ing of  neurologic  surgery  in  Hopkins. 

The  achievements  of  this  department  have  contributed  some  of  the  finest 
gems  to  the  crown  of  modern  neurologic  surgery,  and  while  they  are  unques- 
tionably due  to  the  genius  of  the  brilliant  men  who  have  presided  over  it, 
it  cannot  be  doubted  that  the  stimulus  of  Dr.  Halsted's  example  as  an  inves- 
tigator, his  proximity,  and  the  suggestiveness  of  his  observations  have  served 
to  spur  the  men  whom  he  had  chosen  for  this  special  task,  to  their  best 
efforts.10 

Dr.  Halsted  attacked  every  problem  that  came  before  him  right  at  the 
foundation.  He  was  not  satisfied  with  the  mere  superstructure,  with  the 
shaft  or  capital  of  the  column.  He  would  not  rest  until  he  was  assured  of 
the  security  of  its  base,  and  then  when  this  was  done  he  would  build  a  shaft 
and  capital  of  Corinthian  beauty,  so  finished  and  perfect  in  all  its  parts, 
that  the  world  looked  on  with  admiration  when  he  had  finished  his  work. 

* 
*        * 

The  tendency  of  surgery  today  is  to  lean  too  much  towards  mere  crafts- 
manship, mere  mechanical  expression,  mere  technic.  Admirable  and  neces- 
sary as  is  the  cunning  of  the  hand,  its  obedience  to  command  is  not  all. 
Something  more  is  required.  As  stated  by  Sir  T.  Clifford  Allbutt,  the  most 
learned  living  exponent  of  medicine  in  England,  in  his  memorable  address 
"  On  the  Historical  Relations  of  Medicine  and  Surgery,"  delivered  in  this 
country  nineteen  years  ago : 

"  The  union  of  art  and  science  is  far  from  being,  as  too  often  we  suppose, 
one  merely  of  the  wind  and  helm ;  it  is  one  rather  of  wind  and  wing.   How 

10  In  confirmation  of  the  above  statement  and  of  the  suggestiveness  of  Dr.  Halsted's 
observations,  the  following  quotation  from  one  of  Dr.  W.  E.  Dandy's  early  contribu- 
tions on  "  Ventriculography  Following  the  Injection  of  Air  into  the  Cerebral  Ventri- 
cles "  (Annals  of  Surgery,  July,  1918)  would  seem  appropriate : 

''It  is  largely  due  to  the  frequent  comment  by  Dr.  Halsted  on  the  remarkable 
power  of  intestinal  gases  '  to  perforate  bone,'  that  my  attention  was  drawn  to  its 
practical  possibility  in  the  brain.  Striking  gas  shadows  are  present  in  all  abdominal 
and  thoracic  radiograms.  From  these  and  many  other  normal  and  pathological 
clinical  demonstrations  of  the  radiographic  properties  of  air,  it  is  but  a  step  to  the 
injection  of  gas  into  the  cerebral  ventricles — pneumoventriculography."  This  is 
one  of  the  many  examples  of  how  Dr.  Halsted  scattered  about  his  germinal  ideas. 


mvi  WILLIAM  STEWAET  HALSTED 

these  two  functions,  science  and  craft,  hand  and  mind,  should  live  in  each 
other,  we  see  in  the  fine  arts,  in  the  swift  confederacy  of  hand  and  mind,  in 
Diirer,  Michael  Angelo,  Velasquez,  Rembrandt,  Watteau,  Reynolds,  Watts, 
only  to  mention  the  great  masters  of  the  past.  [Equally  as  well  in  the 
domain  of  music,  Liszt,  Mozart,  Shubert,  Haydn,  Beethoven,  Chopin,  and 
others  who  have  excelled  in  imagination  and  composition  as  well  as  in  pure 
technical  execution.  R.  M.] 

"  The  infinite  delicacy  of  the  educated  senses  is  almost  more  incredible 
than  the  compass  of  the  imagination.  When  they  unite  in  creation,  no 
shadow  is  too  fleeting,  no  line  too  exquisite  for  their  common  engagement 
and  mutual  reinforcement.  The  craft  of  a  Verrocchio  becomes  the  magic 
of  a  Leonardo  da  Vinci  and  Michael  Angelo ;  in  genius  perhaps  the  greatest 
craftsmen  the  world  has  ever  seen,  they  were  as  skilful  to  invent  a  water 
engine,  to  anatomize  a  plant,  or  to  make  a  stone-cutter's  saw,  as  to  paint 
the  lineaments  of  the  soul  and  to  build  the  dome  of  St.  Peter  above  the  clouds 
of  Christendom/' 

It  is  the  harmonious  unison  of  mind  and  the  senses,  the  hand  and  the 
head,  science  and  craft,  exhibited  in  the  supermen  who  have  exalted  the  fine 
arts,  from  antiquity  to  the  present  time,  that  we  find  the  ideal,  difficult  to 
attain  it  is  true,  that  should  be  in  the  mind  of  those  who  aspire  to  the  mas- 
tery of  our  profession. 

Without  pretending  to  soar  with  genius  to  the  heights  of  the  empyrean, 
which  is  given  only  to  a  chosen  few,  the  surgeon,  as  an  exponent  of  the  great- 
est of  the  liberal  arts — the  sculptor  and  moulder  of  "  the  human  form 
divine  " — needs  cultivating  the  subtle  touch,  the  conscient  finger  and  the 
obedient  hand  even  more  than  the  sculptor,  the  painter,  the  musician  or 
other  interpreters  of  art  in  baser  materials. 

But,  even  more,  he  needs  the  broad  vision,  the  cultivated  imagination,  the 
catholicity  of  artistic  taste  and  human  sentiment,  that  give  to  his  manual 
accomplishments  the  attributes  and  qualities  that  glorify  the  hand  in  the 
higher  arts.  To  do  all  this  and  to  be  all  this,  the  Master  Surgeon  must  be 
a  man  of  mind,  a  man  of  thought,  a  man  who  knows  his  province,  the  human 
body,  as  a  whole  and  not  only  one  of  its  parts. 

That  grand  old  Master  Chirurgeon,  Henri  de  Mondeville,  as  far  back  as 
the  thirteenth  century,  seven  hundced  years  ago,  said : 

"  It  is  impossible  to  know  perfectly  the  part,  if  one  is  not  acquainted  with 
the  whole,  even  in  a  gross  way  (grosso  modo) ;  so  it  is  impossible  to  be  a 
good  surgeon  if  one  is  not  familiar  with  the  foundations  and  generalizations 
of  medicine.  On  the  other  hand,  as  it  is  impossible  to  know  the  whole  per- 
fectly if  we  are  not  acquainted  in  a  certain  measure  with  each  of  its  parts ; 
it  is  impossible  for  anyone  to  be  a  good  physician  who  is  absolutely  igno- 
rant of  the  art  of  surgery,  with  a  knowledge  of  its  possibilities  and  its 
limitations." 


AN  APPRECIATION  xxxvii 

It  is  in  this  sense  that  the  surgery  of  the  twentieth  century  is  ploughing 
its  way  to  the  fulfilment  of  its  greatest  destiny.  It  is  in  this  way  that  the 
art  of  the  surgeon,  guided  by  the  light  of  science,  has  risen  from  a  low  state 
of  almost  abject  subserviency  to  its  present  commanding  position.  It  is  by 
following  in  the  wake  of  scientific  progress,  by  utilizing  every  advance  in 
each  one  of  its  elementary  and  ancillary  branches — anatomy  and  histology, 
biology  and  physiology,  physics  and  chemistry,  pathology  and  bacteriology — 
that  surgery  has  sought  and  found  light  in  the  solution  of  its  many  and 
complex  problems. 

It  is  with  this  understanding  and  in  this  sense  that  our  great  friend 
understood  surgery.  It  is  in  his  broad  comprehension  of  and  in  his  capacity 
to  utilize  the  data  furnished  by  the  collateral  sciences  in  their  application 
to  surgical  problems,  that  Professor  Halsted  occupies  a  unique  and  promi- 
nent position  in  the  surgical  world,  and  that  gives  enduring  luster  to  his 
fame. 

* 
*        * 

The  problems  of  the  vascular  system,  especially  of  aneurism,  had  a  great 
fascination  for  Dr.  Halsted  "  and  on  these  he  brought  to  bear  all  the  resources 
of  his  keen  critical  faculties  **'  B  and  of  his  splendid  training  in  anatomy, 
physiology,  and  pathology,  which  he  invariably  supplemented  or  initiated 
by  illuminating  experiments  which  he  performed  himself  or  with  the  col- 

11  Dr.  Halsted's  interest  and  the  importance  he  attached  to  the  surgery  of  the  vascu- 
lar system  is  understood  in  the  light  of  the  following  paragraph.  "  True  also  it  is,  as  I 
have  so  often  said,  that  the  surgeon's  method  of  dealing  with  the  blood  vessels  is  a 
criterion  of  his  proficience  in  his  art "  (Ligation  of  the  Left  Subclavian,  loc.  cit.). 

Dr.  Halsted  evidently  agreed  with  Ballance  and  Edmunds  in  their  monumental 
work  on  the  "  Ligation  of  the  Great  Arteries  in  Continuity,"  (1891),  when  they  began 
their  chapter  on  the  history  of  the  ligature  by  stating  that  "  the  surgery  of  the  arteries 
is  the  very  foundation  of  surgery." 

"Dr.  Halsted's  reflective  mind  and  philosophic  attitude  toward  surgical  problems 
are  well  illustrated  in  the  following  passage  from  his  masterly  monograph  on  the 
"  Ligation  of  the  Left  Subclavian  Artery  " :  "  What  surgeon  called  upon  to  treat  a 
large  aneurism  of  the  neck  or  groin  has  not  experienced  the  disturbing  sensations 
which  only  such  tumors  can  arouse?  When  confronted  with  an  inoperable  malignant 
neoplasm  one  feels  the  great  pity  of  it,  but  not,  as  in  the  case  of  an  aneurism,  a 
peremptory  challenge  to  face  the  exigency  and  cope  promptly  with  a  situation  de- 
manding skilful,  resourceful  and  possibly  even  a  temerous  intervention.  Few  of  the 
surgeons  to  come  will  have  occasion  to  be  stirred  as  Valentine  Mott  must  have  been 
by  his  dramatic  experience  in  ligating  the  common  iliac  artery.  The  surgeon  of 
today  looks  rather  to  Science  than  to  his  art  for  stimulating  rewards  of  his  endeavor. 
In  ligating  the  first  portion  of  the  left  subclavian  within  the  chest  the  operator  may 
not,  as  formerly,  be  more  greatly  impressed  by  the  magnitude  and  cleverness  of  his 
performance  than  by  the  miraculous  effect  of  the  ligation  of  the  artery  upon  the 


xxxviii  WILLIAM  STEWART  HALSTED 

laboration  of  a  group  of  most  able  and  faithful  assistants.  In  this,  as  in  all 
his  numerous  scientific  researches,  his  experimental  work  was  conducted  in 
the  Hunterian  laboratory  which  has  been  made  famous  throughout  the  sur- 
gical world  by  the  many  and  enduring  contributions  that  have  emanated 
from  it.  From  all  of  these,  important  deductions  followed,  which  left  a 
residue  of  precious  metal  in  the  treasury  of  Science.  For  instance,  his  now 
well  known  generalization,  referred  to  as  Halsted's  Law — that  a  transplant 
of  a  portion  of  a  ductless  gland  will  survive  only  when  a  physiological  deficit 
has  been  produced.  This  he  evolved  out  of  his  experimental  work  on  the 
thyroid,  parathyroids  and  thymus.  His  researches  on  the  causes  of  the  dila- 
tation of  an  artery  on  the  proximal  side  of  an  arteriovenous  fistula,  and  the 
probable  extension  of  this  change  in  the  arterial  walls  from  the  fistula 
upwards  toward  the  aorta  and  even  the  heart,  and,  conversely,  the  reasons 
why  an  artery  dilated  on  the  distal  side  of  a  constriction  in  its  lumen — which 
he  was  the  first  to  observe — accounts  for  the  predisposition  to  subclavian 
aneurisms  when  this  artery  rests  on  a  cervical  rib,  roused  new  interest  in  a 
hitherto  unsuspected  pathological  condition  and  paved  the  way  for  further 
research  and  clinical  application. 

The  qualities  of  thoroughness,  absolute  scientific  honesty,  accuracy,  and 
vision,  which  characterized  Dr.  Halsted  in  all  his  clinical  undertakings, 
likewise  distinguished  his  experimental  work  and  gave  to  his  conclusions 
the  greatest  value.  His  investigations  into  the  effect  of  the  partial  and 
complete  occlusion  of  the  aorta  and  other  great  arteries,  by  constricting 
them  with  an  aluminum  band,  strips  of  fascia  or  of  ox-aorta,  and  the  study  of 
the  effects  of  arterio-venous  aneurisms  on  the  heart,  which  were  undertaken 
by  Mont  Reid  under  his  direction,  and  other  investigations  of  a  like  charac- 
ter, too  numerous  to  mention,  are  characterized  by  the  same  rigid  discipline 
which,  as  Leriche  puts  it,  would  have  been  worthy  of  a  Claude  Bernard.  In 
these  researches,  he  was  even  greater  as  a  physiologist  than  as  a  surgeon. 

great,  pulsating  tumor  which  with  each  beat  of  the  heart  jarred  the  whole  frame 
of  the  sufferer. 

"The  moment  of  tying  the  ligature  is  indeed  a  dramatic  one.  The  monstrous, 
booming  tumor  is  stilled  by  a  tiny  thread,  the  tempest  silenced  by  the  magic  wand." 
(Johns  Hopkins  Hosp.  Reports,  vol.  xxi,  p.  5.) 

13 "  One  of  the  chief  fascinations  of  surgery  is  the  management  of  wounded  vessels, 
the  avoidance  of  haemorrhage.  The  only  weapon  with  which  the  unconscious  patient 
can  immediately  retaliate  upon  the  incompetent  surgeon  is  haemorrhage.  If  he  bleeds 
to  death,  it  may  be  presumed  that  the  surgeon  is  to  blame;  whereas  if  he  dies  of 
pnoumonia,  peritonitis  or  other  infection,  or  from  an  unphysiological  operative  per- 
formance, the  surgeon's  incompetence  may  not  be  so  evident."  (Halsted:  "  The  Effect 
of  Ligation  of  the  Common  Iliac  on  the  Circulation  and  Function  of  the  Extremity." 
Trans.  Amer.  Surg.  Assoc,  vol.  xxx,  1912.) 


AN  APPRECIATION  xxxix 

Perhaps  to  the  public,  his  most  sensational  achievement,  in  connection 
with  the  problems  of  the  circulation,  is  his  report  of  the  successful  trans- 
plantation and  reimplantation  of  the  amputated  legs  of  dogs,  without  restor- 
ing the  continuity  of  the  divided  blood  vessels,  an  experimental  feat  which 
was  accomplished  under  his  direction  by  his  assistants,  Reichert  and  Reid, 
and  is  among  the  latest  of  his  contributions.  This  performance  had  been 
done  previously  by  Carrel  and  others,  but  always  conditioned  on  the  reestab- 
lishment  of  the  circulation  in  the  main  vessels  of  the  limb  by  arterial  suture. 
Thus  the  miracle  of  transplanting  the  leg  of  a  negro  slave  to  the  amputated 
stump  of  his  white  master,  which  is  a  part  of  the  traditions  that  encircle  the 
lives  of  Saints  Cosmas  and  Damian,  has  actually  been  brought  within  the 
pale  of  possibility  by  Dr.  Halsted's  demonstrations  in  the  lower  species.  In 
connection  with  this  miraculous  operation,  a  little  note,  quoted  from  Osier, 
is  interesting: 

"  These  practitioners,  who  became  the  Christian  saints  of  surgery,  suffered 
martyrdom  in  Cilicia  in  the  third  century.  In  their  western  mother  church 
in  the  Roman  Forum,  I  have  seen  the  little  parcel,  said  to  contain  the  instru- 
ments with  which  they  performed  the  most  famous  operation  in  hagiological 
surgery — substitution  of  the  healthy  thigh  of  a  just  dead  man  for  one  that 
was  gangrenous."    {Lancet,  May  8,  1915.) 


The  one  surgeon  Halsted  perhaps  admired  more  than  any  other  was  the 
late  Theodor  Kocher,  of  Berne,  Switzerland.  We  are  told  by  Cushing,  who 
had  studied  under  both  masters  and  who  knew  them  perfectly,  that  "  the 
two  men,  in  manner  and  methods  surgical,  in  imagination  and  ideals,  had 
very  much  in  common.  Both  of  them  held  their  professorships  for  an 
unusual  number  of  }rears — Kocher  for  forty-five  years  and  Halsted  for 
thirty-three  years."  This  opinion  is  fully  confirmed  by  the  following  note 
of  appreciation  which  appears  very  appropriately  in  Halsted's  "  Operative 
Story  of  Goitre"  (1922). 

"  Many  times  during  the  past  twenty  years  I  have  stood  by  the  side  of 
Professor  Kocher  at  the  operating  table,  enjoying  the  rare  experience  of 
feeling  in  quite  complete  harmony  with  the  methods  of  the  operator,  and 
it  is  a  pleasure  to  give  expression  to  the  sense  of  great  obligation  which  I 
feel  to  this  gifted  master  of  his  Art  and  Science." 

As  his  eminent  pupil,  Cushing,  who  had  exceptional  opportunities  for 
observing  the  characteristics  of  his  great  teacher,  has  well  said :  "  He  had  a 
rare  form  of  inspiration  which  sees  problems,  and  the  technical  ability 
combined  with  persistence  which  enabled  him  to  attack  them  with  a  pros- 
pect of  successful  issue." 


xl  WILLIAM  STEWART  HALSTED 

In  this  respect,  Dr.  Halsted's  investigative  and  analytical  turn  of  mind 
reminded  one  of  John  Hunter,  for  whom  he  had  the  greatest  admiration 
and  of  whom  he  once  said,  "  John  Hunter's  name  is  eclipsed  by  that  of  no 
other  surgeon,  and  for  the  fame  of  his  contributions,  particularly  to  biology 
and  physiolog}1,  an  inextinguishable  lamp  will  forever  burn."  (Yale  Ad- 
dress, 1904.) 

Not  unlike  Hunter,  he  could  well  say,  when  facing  an  obscure  problem 
which  could  not  be  solved  by  mere  theorizing,  "  Why  think  ?  Why  not  try 
the  experiment  ?  "  How  faithfully  Halsted  exhibits  the  workings  of  his  own 
mind  when,  in  speaking  of  Hunter,  he  said :  "  How  fascinating  to  follow 
the  groping  in  the  dark  and  the  searching  light  of  a  great  mind !  How 
refreshing,  and  what  a  lesson  is  his  honest  doubt ! " 


Dr.  Halsted's  literary  productions  were  characterized  by  the  same  dis- 
tinctive, painstaking  thoroughness  and  attention  to  detail  which  distin- 
guishes all  his  work.  His  major  monographs  on  the  Surgery  of  the  Intes- 
tines, on  the  Radical  Cure  of  Hernia,  on  the  Surgical  Treatment  of  Cancer 
of  the  Breast,  on  the  Common  Bile  Duct,  on  the  Surgery  of  the  Left  Sub- 
clavian, on  the  Effect  of  Ligation  of  the  Common  Iliac  Arteries,  on  the  Sig- 
nificance of  the  Thymus  in  Graves'  Disease:  his  collected  papers  on  the 
parathyroids,  his  Operative  Story  of  Goitre;  on  the  Partial  Occlusion  of  the 
Aorta  and  Other  Great  Arteries  with  Aluminum  Bands,  are  examples  of 
contributions"  which  are  universally  recognized  as  epochal  in  importance, 
not  only  in  virtue  of  their  originality  and  suggestiveness,  but  because  of  their 
searching  analysis  of  the  experiences  of  other  operators  as  they  are  recorded 
in  the  literature.  His  complete  monographs  represerjt  an  immense  amount 
of  bibliographic  research ;  not  mere  compilations,  but  critical  analyses,  with 
commentaries  and  criticisms  on  each  case  which  add  immensely  to  the  value 
of  the  compilation.  His  comments  and  criticisms,  usually  short  and  pithy, 
are  always  illuminating  and  contain  the  very  kernel  of  the  knowledge  one 
is  seeking,  and  reflect  the  mind  of  the  man  who  knew  every  inch  of  the 
ground  that  he  was  treading  upon. 

The  great  labor  and  time  required  in  the  preparation  of  his  opera  magna 
necessarily  limited  his  literary  output  to  a  relatively  small  number  of  yearly 
productions,  but  each  one  of  these  works  is  a  landmark  in  the  history  of  the 

"  No  attempt  is  made  in  this  address  to  quote  exact  titles  or  references  as  these 
will  appear  in  the  complete  Bibliography  which  is  to  accompany  the  two  volumes  of 
Professor  Halsted's  Collected  Payers,  now  in  course  of  preparation  by  Dr.  \Y.  C. 
Burket. 


AN  APPRECIATION  xli 

subject.  He  was  well  aware  that  the  surgical  world  had  learned  to  expect 
great  things  of  him,  and  he  spared  no  labor  to  rise  above  the  level  of  the 
highest  expectation. 

To  the  cognoscenti  in  the  highly  technical  subjects  which  engaged  his 
attention,  the  appearance  of  one  of  his  books  or  papers  was  always  an  event 
which  promised  an  intellectual  feast,  rich  in  vitamines,  which  was  to  be 
degustated  with  delight  but  which  had  to  be  assimilated  slowly.  His  shorter 
papers  gave  an  account  of  the  gist  and  trend  of  his  activities.  His  pupils 
and  co-workers  often  supplemented  his  initial  and  germinal  ideas  which  he 
furnished  in  abundance,  like  the  acorns  of  a  giant  oak  from  which  spring 
other  trees,  vigorous  and  strong  with  the  sap  of  the  primal  trunk. 

Modest,  self-repressed,  shunning  the  limelight  of  publicity,  he  never 
obtruded  his  personality  or  exploited  his  merits  or  achievements  as  claims 
for  priorit}',  only  referring  to  himself  in  the  most  impersonal  way  and 
always  allowing  the  facts  to  speak  for  themselves.  In  this  he  seems  to  have 
inherited  the  Baconian  precept  that,  "A  man  can  scarce  allege  his  own 
merits  with  modesty,  much  less  extoll  them Such  things  are  grace- 
ful in  a  friend's  mouth  which  are  blushing  in  a  man's  own." 

Cushing  is  right  when  he  describes  Halsted  as  an  aristocrat  in  his  breed- 
ing, for  if  there  was  anything  that  he  detested  most  cordially  it  was  vul- 
garity, coarseness  and  undue  familiarity.  Though  over  modest  and  retiring, 
he  had  a  full  consciousness  of  the  dignity  of  his  rights ;  "  Mens  sibi  conscia 
recti "  expresses  his  attitude  of  mind  as  he  walked  through  life. 

Though  shy  and  reserved  and  undemonstrative,  caring  little  for  the 
"  gregarious  gathering  of  men  "  as  Cushing  well  expresses  it,  and  living 
largely  to  himself  in  his  home,  his  laboratory,  and  his  clinic,  he  delighted 
in  the  company  of  his  pupils,  immediate  associates  and  a  few  chosen  friends. 
With  these,  he  was  expansive  and  the  glow  and  warmth  of  his  friendship 
melted  whatever  restraint  had  been  imposed  upon  those  who  first  approached 
him  and  who  were  kept  at  a  distance  by  his  punctilious  politeness  and  adhe- 
sion to  conventional  formalities.  To  those  who  were  privileged  to  bask  in 
the  sunshine  of  his  friendship,  the  true  nature  of  the  man  was  revealed  in 
all  its  splendor.  When  he  allowed  his  mind  to  expand  freely  in  confidence, 
without  restraint,  his  breadth  of  thought,  his  wide  culture,  his  intimate 
knowledge  of  the  greatest  leaders  of  the  profession  throughout  the  world, 
whom  he  met  in  his  frequent  travels,  added  to  the  amenity  and  suggestive: 
ness  of  his  conversation.  Generous,  liberal,  and  hospitable  to  a  fault,  his 
kindliness,  sympathy,  and  unequalled  liberality  in  helping  the  younger  men 
to  accomplish  great  undertakings,  by  encouraging  them  through  privileges 
and  opportunities  which  he  secured  for  them,  are  all  qualities  which  account 
in  a  great  measure  for  the  admiration  and  loyalty  that  is  so  notably  dis- 


xlii  WILLIAM  STEWART  HALSTED 

played  by  his  pupils  and  associates — an  admiration,  love  and  loyalty  that 
only  grew  deeper  and  stronger  as  the  years  rolled  by. 

I  cannot  think  of  Professor  Halsted  without  associating  him  with  his 
pupils  and  collaborators.  I  see  him  as  the  central  figure  in  a  great  historic 
painting.  I  see  him  as  I  have  seen  Ambroise  Pare  holding  the  ligature  in 
hand,  spurning  the  hot  iron  and  boiling  oil  on  the  battlefield  of  Metz,  as 
depicted  in  the  great  panel  at  the  Ecole  de  Medecine  at  Paris.  I  see  him  as 
we  have  seen  John  Hunter  and  his  pupils ;  as  we  see  Claude  Bernard  in  'his 
laboratory  in  the  College  de  France,  as  Velpeau  is  depicted,  demonstrating 
a  great  lesson  in  surgical  anatomy;  as  Billroth  stands  surrounded  by  his 
devoted  coterie  of  assistants  and  pupils — all  destined  to  be  the  greatest 
leaders  in  the  Austrian  and  German  universities.  I  see  him  like  Pasteur, 
surrounded  by  his  pupils  and  associates  (Duclaux,  Eoux,  Chamberland, 
Metchnikoff,  Calmette)  and  again  in  the  grand  tableau  representing  the 
meeting  of  Pasteur  and  Lister  in  the  great  amphitheatre  of  the  Sorbonne, 
together  receiving  the  homage  and  plaudits  of  the  assembled  representatives 
of  the  civilized  world  (1892).  I  see  him  as  Pean  is  seen,  demonstrating  the 
control  of  haemorrhage  in  operations  by  forcipressure  at  the  Hopital  Inter- 
national. I  see  him  as  v.  Bergmann,  head  of  German  surgery,  operating  at 
the  Charite  in  Berlin  surrounded  by  his  now  famous  pupils;  as  Felix 
Guyon  and  his  staff  at  the  head  of  the  great  school  of  genitourinary  prac- 
tice at  the  Hopital  Necker;  as  Trousseau,  surrounded  by  a  group  of  his 
pupils,  all  exceptional  men  and  teachers,  all  attached  to  him  by  ties  of  the 
deepest  affection.  I  think  of  him  as  I  see  Gross  at  Jefferson ;  Agnew  at  the 
Pennsylvania  Hospital;  Bigelow  at  the  Massachusetts  General  Hospital. 
These  are  great  historic  pictures,  which  we  have  all  seen  and  admired  not 
only  because  of  the  tributes  that  the  masters  of  one  art  have  rendered  to  the 
masters  of  another;  not  only  because  of  the  historic  association,  which  re- 
minds us  of  the  wonderful  evolution  and  progress  of  medicine,  nor  because 
of  the  inspiration  that  they  give  to  succeeding  generations,  but,  even  more, 
because  of  their  symbolic  significance ;  by  the  message  that  they  bring  to  us 
from  the  torch-bearers  of  humanity,  whose  burden  is  to  transfer  the  undy- 
ing fire  of  progress  from  one  generation  to  another.  These  historic  pictures, 
in  the  light  of  this  interpretation,  suggest  the  familiar  lines :"....  The 
torch :  Be  yours  to  hold  it  high.  We  shall  not  sleep,  if  ye  break  faith  witli 
us  who  die  !  " 

The  Evangel  warns  us :  "  As  ye  sow,  so  shall  ye  reap." 

Professor  Halsted  died  without  offspring,  but  Nature,  as  if  repentant  for 

her  unkindness,  endowed  him  with  a  brain  of  prodigious  fertility  from 

which  has  sprung  a  numerous  intellectual  family  of  supermen.   Dr.  Halsted 

has  given  proof  of  his  genius  in  many  ways.   He  was  great  in  his  art.   He 


AN  APPKECIATION  xliii 

was  great  in  his  science.  He  was  great  in  his  rare  appreciation  of  the  unity 
of  the  art  and  science  of  surgery  and  of  the  correlation  of  the  medical 
sciences  in  general,  which  gave  him  a  unique  distinction  as  a  teacher  of  sur- 
gery. He  was  great  as  the  father  and  founder  of  a  school  of  surgery  which 
since  its  existence  has  stood  unsurpassed  in  surgical  scholarship,  in  surgical 
craft  and  in  the  attainment  of  surgical  ideals  and  achievements.  But  in 
none  of  these  was  he  greater  than  in  the  selection  of  the  group  of  young  men 
whom  he  chose  to  carry  on  his  apostolate  and  to  transmit  his  teachings. 

"  By  their  fruits  shall  ye  know  them,"  said  the  Evangelist,  and  by  the 
seed  of  his  culture  and  nurture  the  world  now  knows  no  richer  harvest. 

As  I  recall  the  great  attributes  of  mind  so  characteristic  of  our  departed 
friend,  and  remember  the  singular  elevation  of  his  thought,  I  find  him  in 
notable  harmony  with  Carlyle's  brief  sketch  of  man's  place  in  the  universe : 
"  He  is  of  the  Earth,  but  his  thoughts  are  with  the  stars.  Mean  and  petty 
his  wants  and  his  desires,  yet  they  serve  a  Soul  exalted  with  grand  and 
glorious  aims — with  immortal  longings,  with  thoughts  which  sweep  the 
heavens  and  wander  through  eternity.  A  pigmy  standing  on  the  outward 
crust  of  this  small  planet,  his  far-reaching  Spirit  stretches  outward  to  the 
Infinite,  and  there  alone  finds  rest." 

"  Sleep  sweetly,  tender  heart,  in  peace ! 
Sleep,  noble  spirit,  imperial  soul, 
While  the  stars  burn,  the  moons  increase, 
And  the  great  ages  onward  roll." 


BLOOD  REFUSION 

AND 

TRANSFUSION 


REFUSION  IN  THE  TREATMENT  OF  CARBONIC  OXIDE 
POISONING1 

Contributions  to  the  treatment  of  cases  poisoned  by  carbonic  oxide,  the 
most  noxious  constituent  of  coal  and  illuminating  gases,  are  especially 
worthy  of  consideration  because  of  the  great  frequency  of  and  mortality 
from  this  form  of  poisoning.  In  Adolph  Lesser's  2  tables  carbonic  oxide 
figures  as  the  most  common  poison,  and  the  one  which  yields  the  highest 
percentage  of  cases.  Refusion  of  blood  is  literally  a  depletory  transfusion, 
in  which  the  blood  withdrawn  is  returned  to  the  circulation  of  the  loser. 
Volkmann 3  in  discussing  exarticulation  at  the  hip- joint,  suggests  the  feasi- 
bility of  catching  the  blood  lost,  peradventure,  in  this  operation,  and  re- 
turning it  to  the  loser  through  the  divided  femoral  vein.  And  Esmarch  * 
has,  in  one  instance,  endeavored  to  act  in  accordance  with  Volkmann's 
suggestion,  but  his  patient  died  while  preparations  were  being  made  for 
transfusion.  Hueter,5  in  frost  gangrene  of  both  feet,  transfused  centrif- 
ugally  350  c.  cm.  of  the  patient's  own  blood,  defibrinated,  into  the  left 
posterior  tibial  artery;  and  believes  that  he  thereby  preserved  a  portion  of 
the  frozen  part.  The  right  foot,  untransfused,  underwent  an  extensive 
forfeiture.  Highmore,6  evidently  not  aware  that  it  had  already  occurred  to 
others  to  refuse  blood,  offers  "remarks  on  an  overlooked  source  of  blood 
supply  for  transfusion  in  postpartum  haemorrhage,"  and  recommends  util- 
izing the  blood  lost  by  the  mother.  Other  than  these,  I  know  of  no  hints  or 
attempts  at  refusion. 

In  carbonic  oxide  poisoning,  refusion  involves  an  additional  factor — 
viz..  the  oxygenation  of  the  poisoned  blood  employed — and  is,  therefore,  an 

1  Presented  at  the  New  York  Surgical  Society.  November  13.  1SS3.  This  is  Dr. 
Halsted"s  first  published  contribution  to  surgery.  See  page  14. — Editor. 

N.  York  M.  J.,  1883.  xxxviii.  625-629. 

Aho:  Med.  News.  Phila..  1SS3.  xliii.  622-626. 

Also:  Ann.  Anat.  &  Surg.,  Brooklyn.  X.  Y..  1884,  ix.  7-21.   (Reprinted.) 

1  Virchow's  Archiv,  lxxxiii.  2.  p.  193, 1881. 

3Drei  Falle  von  Exarticulation  des  Oberschenkels  im  Huftgelenk.  R.  Yolkmann, 
Deutsche  Klinik,  1S68.  p.  382. 

4H.  Leisrink.  Ueber  die  Transfusion  des  Blutes.  Yolkmann 's  Sammlung  Klinischer 
Yortnige,  No.  41.  Landois.  Die  Transfusion  des  Blutes,  p.  327. 

5  E.  Peters.  Die  Arterielle  Transfusion  und  Ihre  Anwendung  bei  Eifrierung.  Greifs- 
waJd,  1874. 

''  Lancet,  London,  1874,  i,  89. 

3 


4  BLOOD  EEFUSION 

infusion  of  the  purified,  defibrinated  for  the  poisoned,  entire  blood  of  the 
individual. 

A  most  radical  case  of  refusion  is  the  following : 

On  May  5,  1883,  Mr.  A.  S.  G.,  aged  fifty-seven,  a  man  of  medium  size 
and  good  physique,  was  found  unconscious  in  a  stateroom  of  the  steamer 
"  Bristol "  by  the  ticket  taker,  who  observed  a  strong  smell  of  gas  in  the 
room.  He  was  taken  in  an  ambulance  to  the  Chambers  Street  Hospital, 
where  he  arrived  at  9.05  a.  m.  The  house  surgeon  states  that,  on  admission, 
the  patient  could  not  be  aroused.  Eespirations  superficial,  pulse  fairly 
strong  and  85  beats  a  minute.  Temperature  not  taken.  Skin  pale  and  cold'; 
lips  slate-colored;  pupils  somewhat  dilated.  Was  put  in  a  hot-air  bath,  and 
given  whiskey  hypodermically.  At  10.30  a.  m.,  when  I  first  saw  the  patient, 
he  was  still  comatose.  His  eyes  were  partly  open,  and  his  pupils  equal, 
slightly  contracted  and  irresponsive  to  light;  face  ashy  pale  and  surface 
of  body  cold.  The  respirations,  28  a  minute,  were  abdominal,  and  so  super- 
ficial that  it  was  almost  impossible  to  count  them;  pulse  96,  small  and  easily 
compressible.  Feeble  conjunctival  and  plantar  reflexes;  other  superficial 
reflexes  absent  except  cremasteric  on  left  side.  Deep  reflexes  could  not  be 
tested  because  of  the  rigidity  which  existed.  Both  arms  were  flexed,  the  right 
more  strongly  than  the  left.  10.50  a.  m.,  right  radial  artery  exposed  above 
wrist  for  about  one  inch,  and  two  ligatures  passed  under  it.  A  canula,  in- 
troduced centripetally  into  the  artery,  was  held  in  place  by  one  ligature; 
the  other  was  used  to  occlude  the  vessel  peripherally.  Through  the  canula 
512  c.  cm.  of  blood  were  withdrawn,  defibrinated,  strained,  and  kept  at  a 
temperature  of  about  37.5°  C,  in  a  transfusive  apparatus.  11.30  a.  m., 
temperature  35.4°  C,  pulse  92,  respiration  22,  full  and  dyspnoeic.  Super- 
ficial reflexes  well  pronounced.  Eyes  closed,  but  patient  can  be  made  to  open 
them.  Eigidity  of  limbs  has,  in  great  measure,  disappeared.  11.32  a.  m., 
288  c.  cm.  of  defibrinated  blood,  all  that  could  be  obtained  from  the  512 
c.  cm.,  were  refused  through  the  canula  in  the  artery  towards  the  heart — 
centripetal  arterial  infusion.  At  11.45  the  injection  was  completed.  Tem- 
perature 36.6°  C,  pulse  104,  respirations  28,  deep  and  labored.  Superficial 
reflexes  possibly  exaggerated.  The  usual  posttransfusion  rigors  lasted  for 
half  an  hour.  12.35  p.  m.,  300  c.  cm.,  withdrawn  as  before,  through  the 
canula,  defibrinated,  and  mixed  with  128  c.  cm.  of  defibrinated  blood  taken 
from  another  patient.  1  p.  m.,  temperature  38.2°  C,  pulse  128,  respira- 
tions 28.  1.05  p.  m.,  patient's  pallor  most  striking;  192  c.  cm.  of  the  mixed 
blood  infused.  The  color  returned  rapidly  to  his  face  when  from  80  to  100 
c.  cm.  had  been  injected ;  the  change  from  a  deathly  white  to  a  healthy  red 
taking  place  in  a  few  seconds.  1.13,  temperature  39.1°,  pulse  120,  respira- 
tions 40.  2.30,  temperature  39.4°,  pulse  140,  respirations  40.  5.30,  tem- 
perature 37.8°,  pulse  116,  respirations  20. 

Patient  has  been  gradually  returning  to  consciousness  si  nee  the  first 
venesection,  and  now  attempts  to  get  out  of  bed. 

May  Gth. — 12.15  a.  m.,  urine  voided  voluntarily  for  the  first  time  since 
admission,  it  having  previously  been  drawn  with  a  catheter.  8.30  a.  m., 
temperature  37°    (normal),  pulse  98,  respirations   20;  patient   in  good 


BLOOD  REFUSION  5 

condition,  but  mentally  still  a  little  dull.  4.30  p.  m.,  patient  eats  well  and 
desires  to  go  home. 

May  7th. — Intellect  perfectly  clear;  remembers  that  the  steward  lighted 
the  gas  in  his  stateroom  about  9.30  p.  m.  the  night  previous  to  his  poison- 
ing, but  that  it  went  out  as  the  door  was  closed;  undressed  himself  in  the 
dark,  went  to  bed,  and  can  recall  nothing  of  the  night;  has  experienced 
none  of  the  unpleasant  after  effects  of  the  poisoning. 

Allowed  to  go  home  to  "Wareham,  Mass.,  about  fifty  hours  after  admission. 

October  8Jtfh. — Have  interviewed  Mr.  A.  S.  G.*  today,  five  and  a  half 
months  after  the  poisoning,  and  ascertained  that  he  has  not  had  a  single 
unpleasant  symptom  referable  to  the  effect  of  the  gas. 

That  this  patient  would  have  recovered  without  such  active  treatment 
is  not  improbable.  It  is,  nevertheless,  certain  that  the  blood-letting  exerted 
a  most  favorable  influence,  changing  almost  instantly  the  entire  aspect  of 
the  case.  The  scarcely  perceptible  respirations  became  at  once  conspicu- 
ously full;  in  a  few  moments  the  absent  superficial  reflexes  had  returned, 
and  the  rigid  arms  relaxed.  The  body  surface  grew  gradually  warmer,  and 
after  the  first  infusion,  the  temperature  had  risen  from  35.4°  C.  36.6°  C. 
(a  rise  of  3°  F.).  The  pulse  and  respirations  kept  pace  with  the  tempera- 
ture. The  first  infusion  prepared  the  subject  for  a  second  depletion,  and 
contributed  to  the  rise  in  temperature,  and  probably  to  the  improved  cir- 
culation. The  second  infusion  was  decidedly  indicated  as  evidenced  by 
the  impression  it  produced  in  the  patient's  color. 

In  the  light  of  Kuhne's 7  experiments  on  animals  it  is  a  question  whether 
the  blood-letting  alone  would  not  have  rescued  all  the  cases  of  carbonic 
oxide  poisoning  in  the  human  subject  in  which  a  depletory  transfusion 
has  been  successful.  Kuhne  (Joe.  cit.)  found  that  venesection  of  itself  could 
save  life  if  the  respirations  were  as  much  as  two  in  a  minute.  From  twenty- 
three  cases  of  transfusion  for  carbonic  oxide  poisoning  of  which  I  have 
notes,  twelve  terminated  favorably.  In  two  (Casse,8  1;  Luhe/  1)  of  the 
twelve  successful  cases  very  small  quantities  of  blood  were  transfused,  and 
without  any  immediate  good  effects.  In  one  (Hueter10)  of  the  remaining 
cases  attempts  at  depletion  were  unsuccessful,  only  a  few  drops  of  blood 
having  been  withdrawn.  In  three  cases  ( Garrigues,"  1;  Halsted,  2)  the 
venesection  exerted  a  decidedly  favorable  influence.   Three  cases  (Badt,12  1; 

7  Centralblatt  fur  Chirg.,  1864,  No.  9. 
f  Presse  Med.,  xxviii,  8,  1876. 

*  Transfusion  bei  Kohlen-oxyd.   Vergiftung  mit  giinstigen  Azgang.   Deutsche  Mil, 
Aerztl.  Ztschr.,  Berl.,  1878,  vii,  263-267. 
10  Berl.  klin.  Wochenschr.,  1870,  No.  28. 
"  New  York  Med.  Journal,  March  3,  1883. 
"Badt,  Verhandlungen,  D.,  Berl.  med.  Gesellschaft,  1,  1866. 


6  BLOOD  EEFUSIOX 

Martin,"  1 ;  Lehmann,"  1 )  are  narrated  in  articles  to  which  I  have  not 
access,  and  so  can  not  arrive  at  any  positive  conclusions  as  to  which  was 
the  more  efficacious  agent,  the  venesection  or  the  transfusion.  In  one  case 
(Konig15)  the  venesection  (the  amount  of  blood  withdrawn  is  not  stated) 
was  attended  with  slight,  and  the  transfusion  with  no  success.  The  two 
remaining  cases  (Jiirgensen,18  1;  Saltzmann,"  1)  were  apparently  benefited 
by  the  transfusion,  and  yet  in  neither  is  any  reference  made  to  the  influ- 
ence of  the  depletion,  although  from  one  (Jiirgensen)  400  c.  cm.,  and 
from  the  other  (Saltzmann)  180  c.  cm.  of  blood  were  abstracted. 

Some,  then,  of  the  cases  claimed  for  transfusion  seem  attributable  to  the 
venesection  which  preceded  it;  and  in  no  instance  has  it  seemed  to  me 
clearly  demonstrable  that  transfusion  has  saved  life  where  venesection  had 
failed. 

A  few  cases  are  reported  by  0.  Kahler,"  Marten,1'  and  others,**  of  vene- 
section in  carboxysmus  with  good  results;  and,  of  the  several  cases  which 
have  come  under  my  care,  I  will  cite  briefly,  in  proof  of  the  efficacy  of 
venesection,  the  most  serious,  one  in  which  depletory  transfusion  was  re- 
sorted to. 

May  5,  1S82,  10.10  a.  m. — Lillie  Bent,  a  robust  girl  of  seventeen,  was 
admitted  to  the  Chambers  Street  Hospital,  suffering  from  illuminating 
gas  poisoning.  The  night  before,  on  retiring,  she  is  supposed  to  have  blown 
out  the  gas  in  her  stateroom  on  the  steamer  "  Providence." 

On  admission  she  is  said  to  have  been  unconscious,  moaning,  and  much 
cyanosed.  Her  respirations  were  shallow,  and  her  pulse  rapid  and  feeble. 
Temperature  not  taken. 

Whiskey  and  digitalis  were  given  hypodermically.  She  was  put  in  a  hot- 
air  bath,  and  hot  cloths  were  applied  to  the  praecordia.  Flagellation  and  the 
inhalation  of  ammonia  would  partially  arouse  her.  Artificial  respiration 
was  tried,  but  with  what  effect  is  not  stated.  She  would  improve  temporarily 
under  the  treatment,  but  when  left  alone  would  return  to  her  previous 
condition. 

"Massmann  (B.  W.),  Beitrage  zur  Casuistik  der  Transfusion  des  Blutes,  Berlin, 
1870. 

"ManmaiiD   (loc.  cit.). 

15  Evers,  Deutsche  Klinik,  8,  9  and  10,  1870. 

in  Berl.  klin.  Wochenschr..  1S70. 

17  Fall  auf  Hoggradig  Koiosvergiftung,  behandledt  med.  Transfusion.  Finska  Lii- 
kareaallskapets.  Handl.  Bd..  19.  p.  266. 

"  O.  Kahler.  Virchows  "  Jahrcsb.,"  1S81.  i.  p.  240. 

"  Marten.  "  Yjhrschr."  f.  g.  Med.,  xxv.  1864,  pp.  197-224. 

"Henrick  Jensen,  in  Helsingor.  "  Hospitals-Tidende  "  2,  R.  i,  25,  26,  1874,  reports  a 
case  of  carbonic  oxide  poisoning  which  is  interesting  from  the  fact  that  decided  reac- 
tion was  observed  during  a  brief  menstruation.  Strange  that  venesection  was  not 
suggested  to  the  author  by  this  circumstance. 


BLOOD  KEFUSION  7 

I  saw  her  about  5  p.m.;  her  temperature  was  39.1°  C,  respirations  40, 
pulse  120 ;  advised  washing  the  stomach  and  large  intestine  with  hot  water 
for  the  purpose  of  further  stimulation.  9  p.  m.,  patient  much  worse,  pulse 
feebler,  more  rapid  and  intermittent;  respirations  very  superficial;  con- 
junctiva insensitive,  and  all  reflexes  absent.  Mouth  frothy;  occasional 
facial  twitchings  and  grinding  of  the  teeth ;  arms  and  legs  rigid — the  flexor 
muscles  overpowering  the  extensors.  9.05  p.  m.,  204  c.  cm.  of  blood  with- 
drawn from  left  basilic  vein.  Upon  this  the  condition  of  the  patient  im- 
proved marvelously;  almost  instantly  her  respirations  became  full  and  her 
pulse  strong  and  less  rapid.  The  rigidity  of  her  limbs  disappeared,  her 
reflexes  returned,  and  she  could  be  aroused  by  shaking  or  speaking  loudly 
to  her.  11  p.  m.,  attempted  to  transfuse  entire  blood  from  a  Behier's  ap- 
paratus into  patient's  right  cephalic  vein,  but  failed  to  introduce  more 
than  30  c.  cm. 

May  6th. — During  the  night  nourishment  was  administered  per  rectum. 
At  6  a.  m.  patient  answers  questions  somewhat  intelligently,  and  at 
9  a.  m.,  takes  nourishment  by  the  mouth. 

May  7th. — Feels  well,  but  weak. 

It  is  difficult  in  any  case  to  know  precisely  how  much  of  the  cure  should 
be  attributed  to  the  treatment.  When,  however,  a  case  like  the  one  just 
narrated,  observed  sufficiently  long  to  exclude  fluctuation,  assumes  a  de- 
cidedly more  serious  aspect,  and  then  is,  almost  instantly,  on  treatment 
transformed  into  rapid  convalescence,  one  feels  justified  in  assigning  a 
cause  to  the  effect. 

Many  apparently  severe  cases  of  carbonic  oxide  poisoning  are  recorded, 
which  have  recovered  more  or  less  promptly  when  exposed  to  fresh  air  and 
stimulation.  Some,  too,  where  oxygen  n  is  believed  to  have  hastened  the 
convalescence. 

But  if,  despite  these  measures,  the  patient's  condition  grows  constantly 
worse,  death  is  virtually  certain  unless  venesection  be  resorted  to. 

From  the  hour  of  her  admission  until  she  was  bled — 11  hours — Lillie 
Bent's  condition  was  growing  gradually  worse,  and  ultimately  became  so 
bad  that  her  case  seemed  hopeless;  this,  in  a  moment,  upon  venesection, 
was  transformed  into  one  of  apparently  certain  recovery. 

The  transfusion  produced  no  appreciable  effect,  as  might  have  been  ex- 
pected from  the  small  amount  of  blood  injected.  As  additional  proof  of 
the  value  of  bleeding  in  carbonic  oxide  poisoning  I  might  allude  to  the 
case  of  her  companion,  who,  occupying  the  stateroom  with  her,  was  like- 

21  Lanz  in  Biel,  "  Schweiz.  Corr.  Bl.,"  i,  12,  1871,  p.  324. 

Two  cases  of  poisoning  with  illuminating  gas  successfully  treated  by  the  inhalation 
of  oxygen.  By  Alonzo  Clark.  New  York  Medical  Journal,  August  11,  1883. 

Lockey  Stewart,  Brit.  Med.  Journal,  September  25,  1875,  p.  302.  Case  of  carbonic 
oxide  poisoning  in  which  the  inhalation  of  oxygen  exerted  no  influence  upon  patient's 
condition. 


8  BLOOD  KEFUSION 

wise  poisoned.  Less  seriously  affected  by  the  gas,  he  was  venesected  while 
convalescing.  Maniacal  and  confined  in  a  straitjacket,  he  was  bled  about 
512  c.  cm.,  and  thereupon  became  so  rational  and  docile  that  it  was  no 
longer  necessary  to  restrain  him.  To  cite,  as  I  might,  other  less  serious 
cases,  in  which  the  beneficial  effect  of  blood-letting  was  less  strikingly 
apparent,  would  be  superfluous. 

Why  then  transfuse,  if  venesection  accomplishes  so  much?  If  for  no 
other  reason,  to  allow  of  repeated  venesection.  The  poisoned  individual 
should  be  bled  freely,  unless  there  be  decided  contraindications,  even  after, 
to  all  appearances,  out  of  danger,  in  the  hope  of  diminishing  the  risk  of 
pernicious  after  effects. 

Although  bleeding  of  itself  will  probably  suffice  to  save  life  in  almost  all 
cases  which  occur  in  practice,  it  has  been  demonstrated  by  Kiihne  (I.  c.) 
that  animals,  poisoned  beyond  hope  of  rescue  by  venesection,  can  be  saved 
by  transfusion.  In  one  of  his  experiments,  where  respiration  had  been 
suspended  seven  minutes,  he  was  still  able  to  restore  life  to  the  animal  by 
the  infusion  of  defibrinated  blood. 

Aside  from  experimental  demonstrations  of  the  value  of  transfusion,  in 
cases  beyond  recall  by  means  of  bleeding,  nothing  could  be  theoretically 
much  more  enticing  than  the  plausibility  of  substituting  blood  corpuscles 
capable  of  taking  up  oxygen,  for  such  as  are  incapacitated  from  so  doing 
by  reason  of  the  somewhat  stable  compound  which  carbonic  oxide  forms 
with  their  haemoglobin.  Thus  the  much  quoted  and  meritorious  experi- 
ments of  Panum  "  have  led  his  partisans  to  believe  in  the  possibility  of 
blood  substitution,  and  to  regard  the  blood  corpuscles  as  something  which 
can  be  taken  from  one  individual  and  transplanted  in  another. 

But  Von  Ott  a  has  shown  the  falsity  of  Panum's  deductions  in  as  much 
as  he  could  obtain  like  results,  although  making  use  of  a  fluid  which  con- 
tained no  morphological  elements. 

Von  Ott  (I.  c.)  has  demonstrated,  furthermore,  that  blood  corpuscles 
infused  into  the  circulation  are  short-lived,  and  that  blood  whether  entire 
or  defibrinated,  for  other  reasons  is  not  only  no  better  than,  but  not  as 
good  as  a  0.06  per  cent  saline  solution  for  transfusion  in  acute  anaemia. 
One  cannot,  therefore,  properly  speak  of  a  substitution  or  transplantation 
of  blood  corpuscles  by  infusion  of  them  into  an  impoverished  circulation. 

Fortunately,  however,  in  carbonic  oxide  poisoning  it  is  merely  necessary 
to  sustain  the  patient  artificially  for  a  brief  period,  and  for  this,  undoubt- 
edly, the  infused  corpuscles  can  serve  as  oxygen  carriers  for  a  sufficiently 
long  time.    For  the  circumstances,  as  Von  Ott's  (I.  c.)  experiments  teach 

n  Archiv.  f.  Path.  Anat.  u.  Phys.,  1863. 
"Archiv.  Path.  Anat.  u.  Phys.,  1883,  p.  114. 


BLOOD  KEFUSION  9 

us,  that  the  infused  corpuscles  do  not  become  integral  constituents  of  the 
new  organism,  but  rather  are  destined  to  a  more  or  less  rapid  disintegration 
and  elimination,  does  not  prevent  them  from  circulating,  and  temporarily 
taking  part  in  the  interchange  of  gases.  Clear,  then,  as  are  the  indications 
for  transfusion,  auxiliary  to  venesection,  in  the  treatment  of  the  cases  under 
consideration,  the  extreme  difficulty  of  obtaining  blood  at  all,  to  say  noth- 
ing of  sufficient  quantity,  has,  up  to  the  present  time,  classified  the  operation 
with  the  rarer  therapeutic  procedures.  And  we  might,  indeed,  in  the  treat- 
ment of  these  cases,  content  ourselves  with  blood-letting,  were  it  not  that 
the  practicability  of  refusion  removes  what  has  been,  perhaps,  the  greatest 
obstacle  to  the  performance  of  transfusion.  To  the  investigations  of 
Hermann,  Donders  2*  and  Podolinski,"  I  owe  the  conception  of  refunding 
the  purified  for  the  poisoned  blood  of  the  victim  of  carbonic  oxide  poisoning. 

Hermann  M  calls  attention  to  the  fact  that  nitrogen  monoxide  can  liber- 
ate the  carbonic  oxide  of  the  carbonoxyhaemoglobin,  and  forms  a  stronger 
combination  with  haemoglobin,  than  does  carbonic  oxide,  and  subsequently 
Donders  (I.  c),  Hermann  and  Podolinski  (I.  c),  find  that  oxygen  or  air 
can,  in  a  few  minutes,  free  carbonic  oxide  from  haemoglobin,  if  passed 
forcibly  and  in  large  quantities  through  the  poisoned  blood. 

As  to  the  best  method  of  infusing  fluids  into  the  circulation,  good  authori- 
ties disagree.  Of  the  four  possible  methods,  centrifugally  or  centripetally 
into  an  artery  or  vein,  the  question  of  centrifugal  venous  infusion  is  enter- 
tained only  to  be  discarded.  Hueter 2T  who  gives  to  Von  Graefe  the  honor 
of  being  the  first  to  draw  attention  to  centrifugal  arterial  transfusion, 
deserves  the  credit  of  having  introduced  it  to  the  profession,  and  strongly 
advocated  the  method. 

Landois,27  too,  while  contrasting,  in  general,  arterial  with  venous  trans- 
fusion prefers,  from  a  physiological  standpoint,  the  arterial,  be  it  centrip- 
etal or  centrifugal.  Cohnheim  **  on  the  other  hand,  expresses  himself 
decidedly  against  centrifugal  arterial  transfusion  essentially  as  follows: 
One  should  surely  under  no  circumstances  inject  peripherally  into  an 
artery;  for  the  peripheral  arterial  branches  contract  with  such  energy 
against  the  foreign  blood  which  is  entering  them,  that  it  is  often  necessary, 
in  order  to  overcome  the  resistance,  to  exercise  pressure  sufficiently  forcible 
to  rupture  the  blood  vessels.  The  case  is  very  different  when  one  injects 
centripetally  into  an  artery  and  employs  no  more  pressure  than  is  required 

24  Archiv.  f.  Phys.,  v,  p.  24. 
*  Archiv.  f.  Phys.,  vi,  p.  553. 

26  Archiv.  fur  Anat.  u.  Phys.,  1869. 

27  Die  Transfusion  des  Blutes.  Leipzig,  1875. 

23  Vorlesungen  iiber  allgemeine  Pathologie,  Bd.  i,  p.  424. 


10  BLOOD  REFUSION 

to  overcome  the  existing  arterial  tension.  The  blood  infused  mingles  at 
once  with  that  which  is  already  present  in  the  artery,  and  flows  without 
resistance  into  the  first  branch  above,  thence  into  its  arterial  and  capillary 
ramifications,  and  from  here  under,  normal  venous  pressure,  to  the  heart. 

Kummell,28  Schede's  assistant,  produced  gangrene  of  the  hand  by  the 
centrifugal  infusion  of  a  saline  solution  into  the  radial  artery,  thus  giving 
us  a  demonstration  of  a  disaster  which  may  attend  this  method,  and  which 
he  might  have  foreseen. 

We  are  then  restricted  to  the  choice  between  centripetal  arterial  and  cen- 
tripetal venous  infusion. 

Hueter's  "  arguments  for  peripheral  or  centrifugal  arterial  transfusion 
hold  good  for  centripetal  arterial  infusion.  He  prefers  the  arterial  to  the 
venous  transfusion  because  the  blood  by  the  former  method  courses  slower 
and  more  uniformly  to  the  heart;  because  the  minutest  air-vesicle  is  re- 
tained in  the  capillaries,  and  because  the  danger  of  phlebitis  is  avoided. 

Landois  (I.  c.)  adds  to  these  advantages  another,  viz.,  that  the  capillary 
system,  like  a  supplementary  filter,  catches  all  foreign  particles  which  may 
be  present. 

The  essential  advantages  of  centripetal  arterial  transfusion  in  profound 
asphyxia,  says  Landois,  can  be  summed  up  as  follows:  (1)  Arterial  blood 
is  thus  most  directly  dispatched  to  the  nerve  centers,  in  consequence  of 
which  the  venous  blood  there  contained  is  propelled  onwards  into  the  veins ; 
and  (2)  the  filling  of  the  arterial  system  rejuvenates  the  feeble  circulation 
by  creating  a  considerable  difference  in  pressure  between  the  arterial  and 
venous  systems. 

Cohnheim  (I.  c),  too,  from  his  experiments  on  animals,  declares  the  cen- 
tral or  centripetal  arterial  transfusion  to  be  the  least  dangerous,  and  at 
the  same  time  the  most  completely  effectual  procedure. 

From  a  practical  standpoint  I  am  also  impelled  to  advocate  centripetal 
arterial  infusion. 

Besides  the  case  already  narrated,  it  has  been  my  good  fortune  to  trans- 
fuse by  this  method  with  most  brilliant  and  unexpected  success  in  two  cases ; 
one  of  acute  anaemia,  and  one  of  septicaemia. 

Joseph  Hart,  aged  eleven  years,  was  admitted  to  Roosevelt  Hospital, 
September  15,  1882,  for  a  compound  comminuted  fracture  of  the  tibia  and 
some  of  the  tarsal  bones.  The  ankle  joint  was  involved  in  the  injury  and 
the  soft  parts  badly  mangled.  The  wheel  of  a  street  car  had  passed  over 
his  leg  the  night  before.  Patient  is  said  to  have  lost  much  blood,  and  the 
cloths  in  which  his  leg  was  Trapped  furnished  evidence  to  that  effect.   The 

"  Centralblatt  f.  Chirg.,  1882,  No.  19. 
"  Langenbcck's  Archiv.,  Bd.  xii. 


BLOOD  REFUSION  11 

parents  would  not  consent  to  an  amputation,  and  the  boy,  although  per- 
fectly conscious  and  able  to  give  an  account  of  himself,  was  not  in  condition 
for  it. 

At  8.30  p.  m.  eleven  or  twelve  hours  after  admission  the  patient  was  cold 
and  unconscious,  and  his  pulse  was  so  rapid  and  feeble  that  it  could  not 
be  counted  satisfactorily.  It  was  estimated  to  be  about  180  per  minute. 
I  injected  192  c.  cm.  of  a  chlor-natrium  solution  (CINa,  5i;  H20,  O.i), 
centripetally  into  the  left  radial  artery,  whereupon  the  pulse  became  quite 
full,  and  135  a  minute ;  the  boy  returned  to  consciousness,  and  his  condition 
seemed  to  warrant  an  attempt  at  amputation — permission  to  do  so  having, 
meanwhile,  been  obtained.  The  administration  of  ether  had  such  a  bad 
effect  on  the  pulse  that  the  operation  was  deferred,  and  the  leg  placed  in  a 
hot  water  bath.  Patient  continued  to  improve  and  survived  an  amputation 
of  the  leg  performed  by  Dr.  Sands  twenty-five  days  after  admission. 

On  March  18,  1883,  at  Ward's  Island,  I  infused  defibrinated  blood 
centripetally  into  the  radial  artery,  in  a  case  of  septicaemia. 

The  patient,  an  Italian  about  40  years  of  age,  had  suffered  for  several 
months  from  a  suppurative  disease  of  the  ankle  and  some  of  the  tarsal  joints. 
For  about  one  week  prior  to  the  operation  he  had,  almost  daily,  well  pro- 
He  was  so  feeble  that  to  amputate  was  deemed  inadvisable  even  as  a  last 
resort.  A  depletory  transfusion  was  accordingly  undertaken.  A  stout  phil- 
anthropic German  offered  to  furnish  the  blood.  So  plentiful  was  his  sub- 
cutaneous fat  that  not  a  vein  could  be  seen,  althoixgh  his  arm  had  been 
carefully  constricted  below  the  point  at  which  the  basilic  vein  usually  per- 
forates the  deep  fascia.  Dissection  for  a  vein,  prolonged  until  even  the 
would-be-donor  appeared  to  be  willing  to  have  the  search  discontinued, 
failed  to  discover  one.  Thereupon  the  radial  artery  was  exposed  without 
difficult}',  although  our  subject  fainted  as  the  incision  was  being  made 
through  the  integument,  and  so  necessitated  the  completion  of  the  operation 
upon  the  floor.  The  Italian  was  next  depleted  through  his  right  radial 
artery  until  the  arterial  tension  was  barely  sufficient  to  throw  a  jet  across 
the  graduated  jar  into  which  178  c.  cm.  had  been  allowed  to  flow. 

Immediately  thereupon  186  c.  cm.  of  defibrinated  blood  was  infused  cen- 
tripetally into  the  artery.  In  a  few  moments  the  patient's  pulse  had  fallen 
to  120,  which  was  eight  beats  better  to  the  minute  than  before  the  adminis- 
tration of  ether.  The  leg  was  then  amputated  just  below  the  middle.  The 
patient's  pulse  112-114,  weak,  but  regular  and  better  than  before  the 
amputation. 

Cardiac  stimulants  were  of  course  freely  administered.  Slight  post- 
transfusion rigor,  and  a  temperature  of  38.8°  C.  On  the  following  morn- 
ing, March  19th,  the  patient's  pulse  was  110,  and  temperature  normal. 
Since  then  uninterrupted  convalescence. 

It  is  only  just  to  add  that  I  have  once  done  centripetal  arterial  infusion 
in  a  desperate  case  of  pyaemia,  where  the  fatal  termination  was  possibly 
precipitated  by  the  operation. 

If  the  infusion  of  defibrinated  blood  influenced  unfavorably  the  action 
of  the  heart,  it  certainly  was,  in  part,  to  be  explained  by  the  too  heroic 


12  BLOOD  REFUSION 

depletion  which  preceded  it.  This  unsuccessful  attempt  should  not  militate 
against  the  method  of  injecting  the  blood,  but  rather  against  the  indication 
for  so  doing,  or  against  the  manner  or  extent  of  the  depletion.  The  main 
argument  of  those  who  prefer  centripetal  venous  to  centripetal  arterial 
infusion  is  that  the  former  is  the  simpler.  If  it  be  true  that  the  latter  is, 
in  any  degree,  the  safer  method,  the  simplicity  of  the  former  does  not  de- 
serve to  be  considered.  Furthermore,  instead  of  being  easier,  I  am  sure 
that  it  is  often  more  difficult  to  find  a  vein  than  to  expose  the  radial  artery. 
It  was,  for  instance,  impossible  to  discover  a  vein  in  the  stout  German 
referred  to  in  this  paper. 

Jennings,81  too,  one  of  the  more  recent  advocates  of  the  intravenous 
method,  without  having  practised  the  arterial,  had  considerable  difficulty 
in  finding  a  vein  in  one  instance ;  and  others  testify  to  the  same  experience. 
The  dangers  of  intravenous  infusion,  such  as  the  introduction  of  air  and 
small  clots,  and  the  overpowering  of  the  heart  by  a  too  rapid  injection,  may 
be,  theoretically,  easy  to  avoid;  but  practically  death  has  frequently  been 
brought  about  by  one  or  more  of  these  causes.  To  the  centripetal  arterial 
infusion  pertain,  theoretically,  none  of  the  dangers  which,  practically,  in 
the  intravenous  method,  are  far  from  always  to  be  avoided.  And  from  a 
practical  standpoint  my  cases,  which,  I  believe,  are  the  first  recorded,  induce 
me  to  advocate  the  centripetal  arterial  method. 

81  Transfusion,  p.  26.  Balliere,  Tindall  &  Cox,  London,  1883. 


CENTRIPETAL  ARTERIAL  TRANSFUSION1 

I  would  like  to  ask  Dr.  Crile  what  he  thinks  of  centripetal  arterial  trans- 
fusion in  a  case  of  weak  heart.  I  remember  he  suggested  the  advisability 
of  this  on  animals.  Some  thirty  years  ago,  in  New  York,  when  I  used  to  see 
a  great  many  cases  of  carbon  dioxide  poisoning,  we  had  many  opportunities 
of  transfusing  the  centripetal  arteries.  We  used  to  take  the  blood  of  the 
patient,  because  it  is  very  important  to  bleed  these  patients,  then  beat  the 
blood  with  nitrogen  and  reintroduce  it  centripetally  into  the  artery;  then 
there  is  no  danger  of  gangrene.  I  would  like  to  know  what  Dr.  Crile 
thinks  of  this  form  of  transfusion.  I  have  been  much  interested  in 
Dr.  Brewer's  apparatus.  "We  have  been  trying  somewhat  the  same  thing 
with  silver  tubes,  but  I  cannot  report  the  results,  as  it  is  in  the  hands  of 
another  man.  Abbe,  many  years  ago,  put  a  glass  tube  in  the  aorta. 

Now,  with  reference  to  another  method  of  transfusion.  I  am  not  recom- 
mending it;  it  is  not  nearly  so  good  as  Crile's,  but  under  certain  circum- 
stances I  have  seen  in  the  operating  room  certain  embarrassment  and  delay 
in  transfusion.  If  two  tubes  are  used,  one  for  the  vessel  of  the  donor  and 
one  for  the  donee,  by  different  operators,  they  can  be  quickly  joined  together. 
Last  October  we  had  some  of  these  tubes  made  in  pairs,  so  one  could  run 
both  arteries  through  each  tube  if  one  so  desires. 

1  Remarks  in  discussion  of  Dr.  George  W.  Crile's  paper,  "  Further  observations  on 
transfusion  with  a  note  on  haemolysis."  American  Surgical  Association,  Philadelphia, 
June  3-5,  1909. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1909,  xxvii,  85-86. 


13 


CEXTEIPETAL  ABTEEIAL  TKAXSFUSIOX  ' 

Dr.  Klopp's  admirable  paper  has  for  me  an  especial  interest,  for  my  first 
published  contribution  to  surgery  was  an  article  which  appeared  nearly 
forty  years  ago  in  the  Annals  of  Anatomy  and  Surgery.  At  the  old  Cham- 
bers Street  Hospital,  a  relief  branch  of  the  Xew  York  Hospital,  we  saw 
many  cases  of  gas  poisoning,  most  of  them  contributed  by  the  night  boats 
plying  between  Xew  York  and  points  along  Long  Island  Sound.  In  a 
number  of  instances  I  practised  what  I  termed  refusion.  The  patients 
would  be  freely  bled  and  their  blood,  defibrinated,  returned  to  them  by  way 
of  the  radial  artery — a  centripetal  arterial  transfusion.  The  idea  of  purify- 
ing and  refunding  the  poisoned  blood  occurred  to  me  on  reading  Hermann's 
Physiology.  Hermann  called  attention  to  the  fact  that  nitrogen  monoxide 
can  liberate  the  carbonic  oxide  of  the  carbonoxy -haemoglobin,  and  forms 
a  stronger  combination  with  haemoglobin  than  carbonic  oxide  does,  and 
several  physiologists  found  subsequently  that  air  can  in  a  few  minutes  free 
carbonic  oxide  from  haemoglobin  if  passed  forcibly  and  in  large  quantities 
through  the  poisoned  blood. 

The  results  in  some  of  our  cases  were  remarkable.  Patients  who  were 
comatose  would  after  blood  letting  promptly  become  conscious  and  even 
quite  rational,  and  on  refusion  of  their  defibrinated  and  depoisoned  blood 
would  improve  still  further,  as  evidenced  particularly  by  their  color,  and 
the  force  of  the  pulse. 

Yon  Graefe  was  the  first  to  suggest  centrifugal,  and  Landois  the  first 
to  recommend  centripetal  arterial  transfusion.  Hueter  advocated  arterial 
transfusion  in  preference  to  venous  because  the  blood  courses  more  slowly 
to  the  heart  and  the  capillaries  filter  off  air  vesicles  and  any  solid  particles 
accidently  introduced.  So  far  as  I  know,  these  cases  of  mine  at  the  Cham- 
bers Street  Hospital  are  the  only  ones  recorded  of  centripetal  arterial  trans- 
fusion in  the  human  subject.  It  is  not  quite  clear  to  me  why  depleting 
transfusion  is  so  seldom  practised  in  cases  of  gas  poisoning.  In  these  days 
of  blood  matching  the  procedure  would  be  relatively  simple. 

1  Remarks  in  discussion  of  Dr.  Edward  J.  Klopp's  paper.  "  Refusion  of  blood  in 
haemorrhage."  The  American  Surgical  Association.  Washington,  D.  C  .  May  2,  1922. 
Tr.  Am.  Surg.  Ass.,  Phila.,  1922.  xl.  218. 


U 


THE  EFFECT  OF  ADDUCTION  AND  ABDUCTION 

ON  THE  LENGTH  OF  THE  LIMB  IN 

FRACTURES  OF  THE  NECK 

OF  THE  FEMUR 


ADDUCTION  AND  ABDUCTION  IN  FEACTUEES  OF  THE  NECK 
OF  THE  FEMUE  ' 

Dr.  W.  S.  Halsted  presented  a  patient  with  fracture  of  the  neck  of  the 
femur  with  abduction,  and  a  specimen  of  intracapsular  fracture  of  the 
neck  of  the  femur  from  a  case  in  which  there  had  been  adduction  and  a 
quarter  of  an  inch  shortening.  He  called  attention  to  the  necessity  of 
making  allowance  for  adduction  and  abduction  in  the  estimation  of  the 
amount  of  shortening  in  these  cases.  From  certain  measurements  made 
upon  dead  and  living  subjects,  he  had  demonstrated  that,  as  abducting  the 
lower  limb  made  it  measure  less  along  the  line  from  the  anterior  superior 
spine  of  the  ilium  to  either  malleolus,  so  adducting  it  made  it  measure  more 
along  the  same  line;  furthermore,  that,  one  leg  being  adducted,  the  other 
must  be  abducted  to  be  brought  parallel  with  it.  Hence,  in  a  fracture  of 
the  neck  of  the  femur  with  adduction,  the  injured  limb  might  actually 
measure  more  than  the  sound  one :  First,  because  it  was  lengthened  by  ad- 
duction; second,  because  its  fellow  was  shortened  by  abduction.  In  the  case 
from  which  his  specimen  had  been  taken  he  had  been  able  to  make  the 
diagnosis  of  fracture,  because  of  the  recognition  of  these  facts.  The  injured 
limb  was  apparently  shortened,  but,  by  measurement  from  the  anterior 
superior  spine  to  the  malleoli,  was  one  eighth  of  an  inch  lengthened, 
although  a  quarter  of  an  inch  shortened  along  Bryant's  line. 

The  patient  with  fracture  of  the  neck  of  the  femur  and  abduction 
had  limbs  of  apparently  equal  length.  Along  Bryant's  line  the  injured 
limb  measured  three-eighths  of  an  inch,  but  from  the  anterior  superior 
spine  of  the  ilium  to  the  malleolus  externus  an  inch  and  a  quarter,  shorter 
than  the  sound  one.  Dr.  Halsted  remarked,  further,  that,  in  cases  in  which, 
measured  on  Bryant's  line,  there  was  equal  shortening,  the  adducted  limbs 
would  render  more  of  a  limp  necessary  than  the  abducted  ones.  In  con- 
sideration thereof,  he  believed  it  unwise  to  allow  the  limb  to  remain  in  an 
adducted  position. 

Dr.  Alfred  C.  Post  remarked,  with  regard  to  the  anatomical  specimen, 
that  it  hardly  seemed  probable  that  such  a  degree  of  absorption  could  have 

1  Presented  at  the  New  York  Surgical  Society,  February  12,  1884.  Previous  to  this 
report  the  effects  on  measurement  of  abduction  and  adduction  in  fractures  of  the 
neck  of  the  femur  had  not  been  mentioned.  W.  S.  H. 

N.  York  M.  J.,  1884,  xxxix,  251. 

Also:  Med.  News,  Phila.,  1884,  xliv,  250. 

3  17 


18         FKACTUKES  OF  NECK  OF  FEMUR 

taken  place  within  two  weeks  unless  there  had  been  some  before.  The 
specimen  itself  would  seem  to  indicate  that  several  months  must  have 
passed  after  the  receipt  of  the  injury. 

Dr.  Halsted  said  the  man  asserted  that  he  had  never  had  any  trouble 
about  his  hip  joint,  nor  received  any  injury,  and  had  never  been  obliged  to 
walk  with  a  limp. 


THE  EFFECTS  OF  ADDUCTION  AND  ABDUCTION  ON  THE 

LENGTH  OF  THE  LIMB  IN  FEACTUEES  OF  THE 

NECK  OF  THE  FEMUR1 

Agreed  though  we  all  are  that  the  pelvis  should  be  horizontal  when 
measurements  to  determine  the  relative  lengths  of  the  limbs  are  made  from 
the  anterior  superior  spinous  processes  of  the  ilia  to  the  malleoli,  very  few 
indeed  are  familiar  with  the  facts  which  make  it  necessanr.   The  reply,  that 

aTS 


TTtlo- 


vim 


Fig.  1. 


an  obliquity  of  the  pelvis  causes  an  apparent  difference  in  the  relative  lengths 
of  the  lower  extremities,  is  true,  but  does  not  explain.  It  implies,  to  be 
sure,  that  one  leg  is  abducted  and  the  other  adducted,  and  yet  this  of  itself 
might  be  possible  without  leading  to  error  by  measurement. 

Thus,  in  Fig.  1,  let  rs  and  Is  represent  the  anterior  superior  spines  of 
the  ilia,  ra  and  la  the  right  and  left  acetabula,  and  rm  and  Im  the  right  and 
left  malleoli  (external  or  internal).  If,  now,  the  pelvis  be  rotated  on  an 
anteroposterior  axis  passing  through  the  left  acetabulum,  la,  the  right  mal- 

1  Read  before  the  Medical  Society  of  the  County  of  New  York,  February  25,  1884. 
N.  York  M.  J.,  1884,  xxxix,  317-319.   (Reprinted.) 
Also:  Med.  Rec,  N.  Y.,  1884,  xxv,  248. 
Also:  Med.  News,  Phila.,  1884,  xliv,  288. 

19 


20 


ADDUCTION  AND  ABDUCTION 


leolus,  rm,  becomes  raised  to  rm' ;  the  right  leg  is  adducted  and  apparently 
shortened,  and  the  left  leg  is  abducted.  Nevertheless,  the  line  rs'rm'  = 
h'lm,  just  as  before  the  line  rsrm  =  lslm  did,  proving  that,  if  our  dia- 
gram be  correct,  measurements  from  spines  to  malleoli  can  determine 
accurately  the  relative  lengths  of  the  limbs,  notwithstanding  an  obliquity 
of  the  pelvis. 

But  we  know,  from  observation  of  the  earlier  stages  of  hip-joint  disease, 
that,  if  the  diseased  limb  be  adducted  and  apparently  shortened,  it  will 
measure  longer  than  the  healthy  limb ;  and,  conversely,  that,  if  the  diseased 


TSq,, 


limb  be  abducted  and  apparently  lengthened,  it  will  be  shorter  by  measure- 
ment than  the  sound  limb. 

This  could  not  be  the  case  if  the  spine,  acetabulum,  and  malleolus  of  one 
side  occupied  the  same  perpendicular  line  as  represented  in  Fig.  1.  We  look, 
then,  to  the  skeleton  for  an  explanation,  and  find  that  the  spines  are  farther 
apart  than  the  acetabula  are.  In  Fig.  2  this  is  illustrated.  Here,  too,  the 
line  rsrm  =  lslm,  provided  the  line  rsls  be  parallel  to  the  line  rmlm,  or,  in 
other  words,  provided  the  pelvis  be  horizontal.  When,  however,  it  is  rotated, 
as  before,  about  an  anteroposterior  axis  through  the  left  acetabulum,  la, 
the  line  rs'rm'  measures  more  than  the  line  h'lm.  Because,  then,  of  the 
tilting  of  the  pelvis,  the  abducted  left  leg  measures  less  than  the  adducted 
rigbt  leg.  Furthermore,  the  abducted  left  leg  measures  less  than  it  did 
when  straight,  and  the  adducted  right  leg  more  than  it  did  when  straight, 
as  a  glance  at  Fig.  3  will  suffice  to  show. 


FRACTURES  OF  NECK  OF  FEMUE 


21 


In  this  figure  the  obtuse-angled  triangle  rsrarm  has,  for  the  sake  of 
clearness,  been  separated  from  Fig.  2,  and  now  it  is  perfectly  evident  that 
when  the  angle  rs  ra  rm  is  made  less  obtuse,  as  it  would  be  by  abducting 
the  leg  rarm,  the  line  rsrm"  measures  less  than  rsrm ;  that  is  to  say,  the 
leg  is  shortened  by  measurement  from  spine  to  malleolus,  and  that  adduct- 
ing  the  leg  until  the  spine  rs,  the  acetabulum  ra,  and  the  malleolus  rm 
occupy  the  same  straight  line,  rsrarm',  lengthens  the  leg  by  measurement. 
For  in  the  one  instance  (in  abduction)  we  measure  one  side  rsrm",  and  in 
the  other  (in  adduction)  rsra  +  rarm  of  the  triangle.  A.  Nelaton  recog- 
nized this  triangle,  and  pictures  it  in  his  "  Elements  de  pathologie  chirur- 
gicale,"  tome  ii,  p.  833. 


?ra 


And,  to  quote  Barwell 2  Gadechens,  in  1836,  called  attention  to  the  fact 
"  that  when  the  ilium  inclines  to  one  side,  its  crista  must  approach  the 
trochanter  of  the  femur ;  thus,  though  the  whole  thigh  may  sink  and  appear 
longer,  the  measurement  between  any  point  of  the  crista  ilii  and  of  the 
thigh  must  be  shorter  than  the  other  limb."  I  do  not  understand  why  he 
did  not  (if  indeed  he  did  not)  draw  the  complementary  conclusion  that 
adduction,  up  to  the  extent  to  which  we  have  already  referred,  must  make 
the  limb  measure  longer,  unless,  as  is  highly  improbable,  he  believed  that 
the  spine,  acetabulum,  and  malleolus  were  normally  on  the  same  perpen- 
dicular, in  which  case  adduction  would  make  the  limb  measure  just  so  much 
shorter  as  abduction  through  the  same  number  of  degrees  would.  I  say 
"  highly  improbable,"  because  Gadechens  speaks  of  a  sinking,  apparent 
lengthening,  and  measured  shortening  of  the  abducted  thigh.   Now,  appar- 

2  Barwell,  "A  Treatise  on  Diseases  of  the  Joints,  1861,  p.  304. 


22 


ADDUCTION  AXD  ABDUCTIOX 


ent  lengthening  with  measured  shortening  of  the  abducted  limb  •would,  if 
the  three  points  above  mentioned  were  on  the  same  perpendicular,  only  be 
possible  provided  the  limbs  were  not  approximated ;  and  if  Gadechens  com- 
pared by  measurement  divergent  limbs,  irrespective  of  the  angles  which 
they  formed  with  the  pelvis,  his  results  could  not  have  been  sufficiently 
constant  to  enable  him  to  arrive  at  the  conclusions  which  he  did.  To  con- 
firm, experimentally,  that  adduction  produces  lengthening  by  measurement 
from  spine  to  malleolus,  the  writer  has  driven  nails  into  cadavers  at  the 
points  mentioned,  and  found  that  adduction  may  give  measured  lengthen- 
ing from  2  to  8  mm.,  and  abduction  measured  shortening  from  2  to  4  cm., 
or  thereabouts,  in  different  cases. 


Fig.  4. 

Clinically,  too,  in  fractures  of  the  neck  of  the  femur,  adduction  and 
abduction  probably  frequently  occur,  and  to  a  considerable  degree.  To 
recognize  these  as  factors  in  the  deformity  is  essential  for  even  an  approxi- 
mate estimation  of  the  amount  of  real  as  distinguished  from  measured  and 
apparent  shortening.  Its  recognition  is  further  of  importance  from  the 
treatment  standpoint. 

If  in  fracture  of  the  neck  of  the  femur  there  be  neither  abduction  nor 
adduction,  the  pelvis  will  be  horizontal  when  the  legs  are  parallel.  In  such 
a  case  the  apparent  shortening,  real  shortening,  and  measured  shortening 
would  be  practically  equal.  Thus,  in  Fig.  4.  the  apparent  shortening  =  lmy, 
the  real  shortening  =  rtx,  and  the  measured  shortening  =  lslm  —  rsrm. 

^Tien,  however,  adduction  is  an  element  in  the  deformity,  there  will  be 
apparent  shortening,  almost  invariably  real  shortening,  and  possibly  meas- 
ured lengthening,  provided  the  adduction  be  considerable  and  the  real 
shortening  not  excessive. 


FRACTURES  OF  NECK  OF  FEMUR 


23 


This  measured  lengthening  I  have  once  observed  in  my  wards  at  Bellevue 
Hospital,  and  had  the  opportunity  to  confirm  the  diagnosis  at  the  autopsy. 
The  case  was  reported  recently  at  the  surgical  society,  and  the  specimen 
of  the  fracture,  which  was  intracapsular,  presented. 

It  is  in  this  particular  variety  of  fracture,  when  associated  with  adduc- 
tion, that  the  diagnosis  might  be  difficult,  if  not  impossible,  unless  the 
special  features  of  the  case  were  recognized. 

Lisfranc  and  Lallemand  have  each  observed  a  case  of  fracture  of  the 
neck  of  the  femur  in  which  the  broken  limb  was  the  longer. 


rm 


Fig.  5. 


Senn,"  referring  to  these  cases,  says  that  "  it  is  impossible  to  conceive  in 
what  manner  the  fracture  could  add  to  the  length  of  the  limb." 

He  was  evidently  unacquainted  with  the  points  upon  which  the  writer  is 
dwelling. 

The  recognition  of  the  adduction  is  furthermore  of  importance  because, 
if  the  limb  be  allowed  to  remain  in  this  position,  the  patient  will  surely 
limp  when  he  walks,  notwithstanding  the  fact  that  there  may  be  measured 
lengthening  and  very  little  real  shortening. 

In  Fig.  5  is  outlined  a  fracture  of  the  neck  of  the  right  femur,  with 
adduction.  The  apparent  shortening,  Imy,  is  excessive,  although  the  real 
shortening,  rtx,  is  inconsiderable.  The  lengthening  by  measurement  equals 
rsrm  —  Islm. 

3 "  Fractures  of  the  Neck  of  the  Femur,"  N.  Senn.  "  Transactions  of  the  American 
Surg.  Assoc,"  vol.  i,  1883. 


24 


ADDUCTION  AND  ABDUCTION 


Figs.  6  and  7  represent  fractures  of  the  neck  of  the  right  femur,  with 
abduction.  In  6  there  is  little  abduction  and  great  real  shortening,  and, 
consequently,  apparent  shortening.  In  7,  much  abduction,  little  real  short - 


rt 


rm 


l?TV 


Fig.  6. — Fracture  of  the  Neck  of  the  Right  Femur,  with  Slight  Abduction. 

Imy,  apparent  shortening;  rtx>lmy,  real  shortening;  Islm —  rsrm>rtz, 
measured  shortening. 


rm 


Fia.  7. — Fracture  of  the  Neck  of  the  Right  Femur,  with  Abduction. 

rmy,  apparent  lengthening;  rtx,  real  shortening;  Islm  —  rsnn,  measured 
shortening. 

ening,  and  hence  apparent  lengthening.  Although  the  measured  shortening 
is  greater  in  7  (the  case  of  apparent  lengthening)  than  in  6,  the  patient 
in  the  case  of  apparent  shortening  (Fig.  6)  would  limp,  and  in  the  other 


FRACTURES  OF  NECK  OF  FEMUR 


25 


might  not.  Apparent  shortening,  consequently,  is  undesirable,  and  should 
be  overcome  if  possible.  Thus  it  becomes  evident  that  statistical  tables 
designed  to  show  how  much  measured  shortening  may  exist  without  caus- 
ing a  limp,  and  how  little  measured  shortening  occurs  in  many  cases  of 
fractures  of  the  neck  of  the  femur,  are  worthless  unless  the  adduction  and 
abduction  which  may  have  been  present  were  recognized. 

Konig*  believes  that  the  amount  of  apparent  lengthening  or  shortening 
equals  the  difference  in  level  between  the  right  and  left  anterior  superior 


Fig.  8. 


spines  of  the  ilia.  That  this  is  not  strictly  accurate  is  shown  in  Fig.  8 ;  for 
the  line  rsz,  which  represents  the  difference  in  the  level  of  the  spines,  is 
longer  than  the  line  y  Im,  which  represents  the  apparent  lengthening.  The 
line  rax=ylm,  but,  unfortunately,  cannot  be  accurately  determined  on 
the  living  subject.  Bryant's  line,  for  obvious  reasons,  is  only  to  be  relied 
upon  when  the  pelvis  is  straight. 

To  determine,  then,  approximately,  the  amount  of  real  shortening,  it  is 
best  that  the  pelvis  should  be  horizontal.  For  the  sake  of  accuracy,  a  Volk- 
mann's  coxankylometer,  or  something  equivalent,  may  be  employed. 

* "  Lehrbuch  der  speciellen  Chirurgie,"  vol.  iii,  p.  267. 


26  ADDUCTION  AND  ABDUCTION 

Or,  if  it  be  difficult  to  straighten  the  pelvis,  one  might  make  use  of  a 
procedure  recommended  by  Giraud-Teulon.  This  consists  in  a  geometrical 
device  for  determining  the  distance  of  either  one  of  the  condyles  of  the 
femur  from  the  center  of  the  cotyloid  cavity.  The  middle  point  of  a  line 
drawn  from  the  anterior  superior  spine  of  the  ilium  to  the  tuberosity  of  the 
ischium  corresponds  quite  closely  to  the  center  of  the  acetabulum.  If,  then, 
a  triangle  be  formed  by  lines  drawn  between  one  of  the  condyles  of  the 
femur,  the  anterior  superior  spine  of  the  ilium,  and  the  tuberosity  of  the 
ischium,  the  length  of  a  line  let  fall  from  the  condyle  selected  (the  apex  of 
the  triangle)  to  the  middle  of  the  base  line  (that  drawn  from  spine  to 
tuberosity)  equals  the  distance  from  said  condyle  to  the  center  of  the 
cotyloid  cavity,  whatever  may  be  the  position  of  the  pelvis  or  femur. 

DISCUSSION 

"  Dr.  Halsted  said  his  remarks  were  directed  specially  to  accidental  frac- 
ture of  the  neck,  and  not  to  cases  of  hip-joint  disease.  He  did  not  think 
that  in  the  former  class  of  cases  the  objection  brought  forward  by  Dr.  Judson 
with  relation  to  the  great  obtuseness  of  the  angle  formed  by  a  line  drawn 
from  the  malleolus  to  the  acetabulum,  and  another  drawn  from  the  superior 
spinous  process  to  the  same  point,  was  well  founded  in  cases  of  the  kind  to 
which  he  referred,  as  was  illustrated  in  the  case  cited.  The  practical  value 
of  the  point  made  in  the  paper  amounted  to  this  in  treatment,  that  by 
recognizing  the  influence  of  abduction  the  position  of  the  leg  could  be 
changed  and  the  patient  saved  the  necessity  afterward  of  walking  with 
a  limp. 

"  Dr.  Halsted  said,  in  regard  to  Dr.  Judson's  idea,  that  the  angle  was 
too  obtuse  to  be  of  any  practical  importance,  and  that  he  believed  that  he 
was  mistaken.  In  the  case  in  Bellevue  Hospital,  which  led  him  to  make  a 
special  study  of  this  subject,  the  patient  stated  that  he  had  never  had  the 
slightest  limp  before.  The  apparent  shortening  was  two  inches,  while  the 
measured  length  of  the  injured  limb  was  one-eighth  of  an  inch  greater  than 
that  of  the  other,  and  hence  it  was  thought  that  there  could  be  no  fracture. 
He  decided,  however,  that  there  was  an  intracapsular  fracture.  There  were 
three  things  that  he  took  into  consideration :  First,  the  abduction,  making 
the  limb  longer;  second,  the  adduction  of  the  other  limb,  which  was  para- 
lyzed, making  it  shorter;  and,  third,  the  fact  that  one  limb  might  be 
naturally  longer  than  the  other.  His  demonstration  had  a  direct  bearing, 
he  thought,  on  both  diagnosis  and  treatment.  With  an  adducted,  impacted 
fracture,  with  apparent  shortening,  the  patient  was  sure  to  limp." 


SURGICAL  TECHNIC 


ASEPTIC   AND  ANTISEPTIC 
SURGERY 


THE  EMPLOYMENT  OF  FINE  SILK  IN  PREFERENCE  TO  CAT- 
GUT AND  THE  ADVANTAGES  OF  TRANSFIXING  TISSUES 
AND  VESSELS  IN  CONTROLLING  HAEMORRHAGE 

ALSO  AN  ACCOUNT  OF  THE  INTRODUCTION  OF  GLOVES,  GUTTA- 
PERCHA  TISSUE   AND   SILVER   FOIL1 

For  a  number  of  years  I  have  had  it  in  mind  to  call  attention  to  the  par- 
ticular method  of  employing  silk  ligatures  and  sutures  which  has  been 
practised  in  the  surgical  clinic  of  The  Johns  Hopkins  University  since  the 
opening  of  The  Johns  Hopkins  Hospital  in  1889,  but  have  hesitated  and 
also  been  eager  to  do  so  for  the  same  reason,  namely,  that  our  school  seems 
to  be  almost  alone  in  its  advocacy  of  the  use  of  this  material. 

Theodor  Kocher,  however,  has  for  many  years  employed  silk  quite  to 
the  exclusion  of  catgut  and  our  position  is  greatly  strengthened  by  the 
support  of  such  eminent  authority. 

Surgeons,  old  and  young,  those  who  have  been  active  and  masterful  in 
the  marvelous  period  of  development  of  antiseptic  surgery,  and  the  medical 
student  who  takes  for  granted  the  healing  of  wounds  per  primam  and  the 
achievements  of  modern  surgery  as  he  does  the  ability  to  speak  his  own 
tongue,  will  be  interested  to  read  the  words  of  Kocher1  spoken  in  1888. 
"  '  Away  with  the  spray ! '  cried  Bruns  3  some  years  ago — Bruns  who  achieved 
so  much  and  who  died,  alas,  so  early — and  gladly  did  one  cast  off  this 
burden.  '  Away  with  protective  ! '  exclaimed  Starcke *  in  an  admirable  essay 
on  the  treatment  of  wounds.  But  with  the  elimination  of  spray  and  pro- 
tective there  are  still  many  of  the  seemingly  essential  features  of  the  anti- 
septic technic  to  be  discarded  before  the  physician  in  general  practice  can 
be  placed  in  that  happy  state  of  mind  which  pertains  to  the  consciousness 
of  his  ability  to  avoid  making  the  famous  seven  errors  of  Nussbaum.  The 
1  away '  must  resound  still  further,  and  we  say,  therefore,  primarily,  away 
with  the  catgut !  and  also :    away  with  all  the  prepared  gauzes,  from  the 

1  This  article  is  placed  exceptionally  out  of  the  chronological  order  aa  it  is  the  only 
approximately  detailed  statement  by  Dr.  Halsted  himself  on  the  subject  of  some  of 
the  more  important  of  his  contributions  to  surgical  technic. — Editor. 

J.  Am.  M.  Ass.,  Chicago,  1913,  lx,  1119-1126.   (Reprinted.) 

2  Kocher:  Eine  einfache  Method  zur  Erzielung  sicherer  Asepsis,  Corr.-Bl.  f.  schweiz. 
Aerzte,  1888,  xviii. 

J  Berl.  klin.  Wchnschr.,  1880,  No.  43. 

4  Vortrag  in  der  Berl.  militararztl.  Gesellsch. 


30  SURGICAL  TECHNIC 

Lister  gauze  to  the  newest  productions  of  the  manufacturers  of  supplies 
for  dressings. 

"  To  what  misfortunes  catgut  can  give  rise  more  than  one  communication 
in  the  medical  journals  of  years  ago  has  testified.  In  the  first  place 
von  Zweifel  called  attention  to  the  decomposition  which  took  place  when 
catgut  was  kept  in  phenolized  oil  as  recommended  by  Lister.  Other  sur- 
geons have  confirmed  the  observations  that  one  may  infect  wounds  directly 
with  catgut  preserved  in  the  manner  mentioned  and  we  also  have  at  one 
time  published  the  case  of  a  woman  whose  death  after  the  excision  of  a 
struma  sarcomatosa  was  attributable  to  the  employment  of  catgut  which 
had  decomposed  in  the  phenolized  oil." 

Kocher  proceeds  to  relate  the  disastrous  experience  he  had  with  catgut 
from  May  to  July,  1887.  Of  thirty-one  operations  performed  in  a  period 
of  seven  weeks,  serious  infection  of  the  wound  occurred  in  twenty-nine. 

In  one  of  the  two  non-infected  cases  silk  was  employed.  Hence  in  this 
particular  "  catgut  period  "  only  one  operative  wound,  a  small  one  in  which 
were  very  few  ligatures,  healed  per  primam.  Catgut  being  totally  dis- 
carded and  silk  reinstated,  the  infections  ceased.  From  that  time  until  the 
present,  except  possibly  for  brief  periods  of  experimentation  with  catgut, 
Professor  Kocher  has,  I  believe,  employed  silk.  I  have  not  heard  him  state 
his  reasons  for  preferring  silk  in  these  days  when  catgut  may  be  perfectly 
sterilized,  but  that  they  are  sound  we  may  be  sure.  I  can  testify  to  the 
admirable  healing  of  his  wounds. 

Our  method  of  employing  silk  differs  quite  essentially  from  Professor 
Kocher's.  The  silk  which  we  use  is  much  finer  than  his  and  we  rely  on 
transfixion  to  prevent  the  ligature  from  slipping. 

I  am  unable  to  say  precisely  when  it  was  that  I  definitely  substituted 
silk  for  catgut.  It  must  have  been  earlier  than  1883,  for  in  that  year  or  in 
1882  Warmbrum  Quilitz  &  Co.  of  Berlin  made  for  me,  in  glass,  bobbins 
of  my  designing,  to  be  held  in  the  left  hand  of  the  operator  during  the  act 
of  ligating  blood  vessels.  A  description  and  illustration  of  these  spools  is 
given  in  The  Johns  Hopkins  Hospital  Reports.6  I  have  employed  them  con- 
tinuously from  the  time  of  their  introduction  to  the  present.  When  the 
operator  desires  to  tie  a  vessel  without  tissue-transfixion  he  is  handed  a 
spool — not  a  thread  cut  to  the  length  desired  for  a  ligature.  With  the  right 
hand  the  silk  is  unwound,  as  required,  from  the  spool  held  loosely  in  the 
left.  Only  two  or  three  yards  are  wound  on  each  spool,  but  enough  for  the 
tying  of  many  arteries;  and  for  each  operation  the  silk  employed  is  sterilized 
only  once.  The  armed  glass  spools  are  steamed  in  heavy  glass  test-tubes 
(Plate  I,  1). 

8  Johns  Hopkins  Hosp.  Rep.,  Bait.,  1891,  ii,  306. 


SURGICAL  TECHNIC  31 

In  the  winter  of  1886  and  1887,  experimenting  on  the  subject  of  intes- 
tinal suture  8  with  Dr.  Franklin  B.  Mall,  I  employed  ordinary,  fine  black 
spool-silk  as  material  for  ligature  and  stitches.  Black  silk  was  selected  in 
preference  to  white  because  it  was  easier  to  see  it  on  the  glass  bobbins  and 
in  the  fresh  wound,  and  it  was  also  more  readily  identified  in  the  healed 
wounds.  The  little  black  loops  of  the  mattress  or  Lembert  stitches  made  a 
striking  picture  after  a  time,  lying  more  or  less  free  under  the  peritonaeum 
along  the  line  of  the  intestinal  suture. 

The  following  winters  1887-1889,  in  my  experiments  on  the  thyroid 
gland,  I  employed  exclusively  the  black  silk,  just  as  we  do  today  and  have 
done  ever  since  the  opening  of  The  Johns  Hopkins  Hospital  twenty -four 
years  ago. 

The  relatively  high  cost  of  catgut,  its  bulkiness,  the  inconveniences  at- 
tending its  use  and  sterilization,  its  inadequacy,  the  uncertainty  as  to  the 
time  required  for  its  absorption,  and  the  reaction  which  it  excites  in  a 
wound,  induced  me  to  discard  it  completely  for  clean  wounds  in  the  sur- 
gery both  of  the  human  subject  and  of  animals.  From  year  to  year  and  for 
various  periods  of  time  I  have  given  the  catgut,  sterilized  by  the  best 
known  American  purveyors  of  this  material,  a  trial,  but  invariably  with 
the  results  which  we  interpreted  as  being  less  perfect  than  with  silk.  Infec- 
tion from  pathogenic  organisms  can,  of  course,  only  rarely  be  ascribed, 
nowadays,  directly  to  the  catgut  sterilized  by  our  most  reliable  firms.  With 
the  fine  silk  in  our  wounds,  which  for  twenty-three  years  have,  as  a  rule, 
been  closed  without  drainage,  suppuration  almost  never  occurs.7  But  cat- 
gut, even  that  which  we  have  no  cause  to  believe  is  not  sterile,  irritates  the 
wound  for  some  reason,  perhaps  because  it  serves  as  culture  medium  for 
saprophytic  organisms  which  are  carried  into  it  from  the  deep  epithelium 
and  follicles  of  the  skin.8 

We  have  frequently  observed  this  irritation  and  have  occasionally  had  the 
opportunity  to  compare  the  reaction  caused  by  catgut  with  that  of  fine  silk 
in  wounds  symmetrically  situated  in  the  same  patient  and  made  at  the  same 
time. 

Let  the  surgeon  interested  in  making  the  comparison,  when  he  has  occa- 
sion to  amputate  both  breasts  for  nonmalignant  disease,  take  a  running 
subcuticular  stitch  on  the  one  side  with  catgut,  on  the  other  with  fine  silk 
(No.  A  or  AA)  and  observe  the  healing  wounds  from  day  to  day;  or  when 

6  These  experiments  were  conducted  in  the  Pathological  Laboratory  of  The  Johns 
Hopkins  Hospital.  Am.  Jour.  Med.  Sci.,  October,  1887,  p.  436. 

7  Johns  Hopkins  Hospital  Reports,  Bait.,  1891,  ii,  No.  5. 

8  The  reader  is  referred  to  the  admirable  work  and  unusually  convincing  articles  of 
Dr.  Y.  Noguchi,  Arch.  f.  klin.  Chir.,  xcvi,  394,  and  xcix,  948. 


32  SURGICAL  TECHNIC 

operating  on  two  goitres  on  the  same  day,  employ  catgut  for  the  platysma 
suture  in  the  one  case  and  very  fine  silk  in  the  other.  There  is  not  only 
greater  local  reaction  in  the  cases  sewed  with  catgut  but  in  them  the  wounds 
will  occasionally  open  at  one  or  more  points  to  discharge  a  few  drops  of 
clear  or  cloudy  fluid. 

Wedded  to  the  use  of  catgut,  the  operator  develops,  undoubtedly,  a 
special  technic  which  enables  him  to  avoid  procedures  which  would  be  likely 
to  cause  trouble  or  inconvenience,  but  on  the  other  hand,  he  is  deprived  of 
very  useful  devices  which  become  indispensable  and  a  delight  to  the  sur- 
geon who  has  acquainted  himself  with  the  possibilities  of  silk  threaded  in 
the  ordinary  fine  straight  needle  of  commerce. 

Straight  needles  of  various  sizes  and  lengths  are  threaded  in  great 
number  with  the  silk  corresponding  in  size,  and  are  coarsely  basted  in  rows 
into  strips  of  thin  muslin  or  gauze  (Plate  I,  2).  The  loaded  strips  are 
folded  and  stored  for  subsequent  use.  The  necessity  for  threading  needles 
in  the  course  of  the  operation  is  thus  obviated  in  great  measure.  Occasion- 
ally more  than  one  hundred  of  these  needles  are  employed  at  one  operation, 
since  our  ligations,  for  the  most  part,  are  made  by  transfixion  of  the  tissues 
about  the  vessel  or  by  piercing  the  vessel  itself  when  it  is  large  or  sufficiently 
important,  or  by  a  combination  (Plate  II,  2)  of  these  methods.  Plate  I,  3, 
illustrates  the  usual  method  of  controlling  haemorrhage  from  the  larger 
vessels  which  have  been  isolated.  For  the. control  of  bleeding  points  when 
the  vessels  have  not  been  isolated,  the  needle  is  passed  first  under  or  between 
the  vessel  or  vessels  to  be  ligated,  and  then  a  second  transfixion  is  made, 
more  superficially,  close  to  the  point  of  the  clamp  and  in  front  of  it;  the 
clamp  is  now  tilted  in  the  opposite  direction  while  the  operator  ties  the  knot 
behind  it  (Plate  II,  1).  Piercing  the  tissues  a  second  time  in  this  manner 
eliminates  the  trouble  of  seeing  to  it  that  the  ligature,  in  the  act  of  tying, 
is  carried  over  the  tip  of  the  artery  clamp.  This  method  enables  one  also 
to  use  to  good  advantage  the  forceps  with  fine  points  which  in  my  opinion 
has  much  to  recommend  them  and  which  in  our  clinic  are  employed  almost 
exclusively,  both  as  clamp  and  needle-holder. 

With  the  finest  silk  and  needles  one  can  perform  feats  in  haemostasis 
which  would  be  very  difficult  or  impossible  with  catgut;  for  example,  the 
control  of  small  bleeding  points  over  the  trachea,  of  the  pia  mater,  of  the 
periosteum,  and  the  suture  of  wounds  of  vessels. 

In  general  terms  ligatures  taken  in  this  way  are  drawn  only  with  firm- 
ness sufficient  to  control  completely  the  bleeding,  and  not  so  tight  as  to 
crush  the  tissues  or  interfere  unnecessarily  with  their  nutrition.  The  same 
tissues  tied  without  transfixion  would  have  to  be  crushed  or  strangulated  by 
the  ligature  and  thus,  at  best,  be  reduced  to  the  condition  of  a  graft  with 


PLATE   I 


y^r* 


1. — Ligature-spools  of  glass.  A 
spool  is  held  in  the  left  hand  while 
the  right  unwinds  only  so  much  of 
the  thread  as  may  be  required  for 
the  ligation  of  one  vessel. 


2.— Reduced  3  5.  To  show  method 
of  basting  the  threaded  needles.  Silk 
Xo.  C.  Needle  Xo.  9.  We  usually 
employ  silk  two  sizes  finer  than  this. 


3. — The  ligation  of 


m  isolated  vein  or  artery  by  transfixion.    The  vessel  has  been  twisted  to 
prevent  bleeding  from  the  needle-prick. 


PLATE    II 


1. — The  usual  method  of  controlling  haem- 
orrhage from  one  or  more  vessels  by  trans- 
fixion. 


Ligation  by  transfixion  of 
non-isolated  vein,  to  be  divided 
at  X.  The  elamp  is  on  the 
tumor-side  of  the  vessel. 


3.— Th.    epithelial  stitch.     I  needle  and 

-        -       Id  \»   much  finer  than  the  drawing 


SURGICAL  TECHNIC  33 

diminished  chances  of  restitution  and  with  increased  danger  of  wound 
infection.  Furthermore,  ligation  without  transfixion  necessitates  the  use 
of  stronger  silk  for  the  reason  that  a  transfixing  ligature  cannot  slip. 

The  surgeon  who  has  not  tested  the  method  will  be  surprised  to  find 
how  large  a  vessel  may  be  safely  entrusted  to  a  transfixion-ligature  of  the 
very  finest  silk.  I  have  seen  a  ligature  of  coarse  silk  which  had  been  tied 
with  crushing  force,  blown  off,  as  it  were,  from  the  aorta  of  a  dog — a  liga- 
ture applied  12  mm.  from  the  proximal  end  of  the  divided  vessel.  This 
same  artery  was  then  safely  obturated  by  a  ligature  of  silk,  No.  A,  which 
pierced  it. 

Repeatedly,  he  who  uses  catgut  finds  himself  tying  with  a  strand  which 
is  coarser  than  the  vessel  to  be  ligated. 

Even  for  long  abdominal  wounds  we  rarely  use  a  coarser  silk  than  No.  C 
(Plate  I,  2).  Occasionally  we  reinforce  with  one  or  two  sutures  of  silver 
wire  which  include  skin  and  the  anterior  and  posterior  layers  of  the  sheath 
of  the  rectus;  otherwise  fine  silk  (Nos.  AA,  A  and  C),  is  used  throughout 
for  sutures  as  well  as  ligatures.  "We  seldom  tie  en  masse  in  the  ordinary 
sense  of  this  term,  and  in  clean  wounds,  I  may  say,  never. 

In  the  control  of  haemorrhage,  parenchymatous  or  otherwise,  we  see  to 
it  that  the  thread  is  always  well  buried  in  the  living  tissue.  It  should  not 
bridge  over  a  dead  space  as  a  chord  subtends  an  arc.  In  ligating,  for  exam- 
ple, the  vessels  of  the  superior  pole  of  a  thyroid  lobe  in  the  course  of  a 
lobectomy  a  fine,  short,  curved  or  straight  needle,  carrying  one  strand  of 
fine  silk  is  passed  behind  or  between  the  vessels,  and  then  through  the 
twisted  artery,  or  vein,  or  both,  and  the  thread  is  tied  on  both  sides  of  the 
clamp.  The  ligation  of  the  superior  thyroid  vessels  is  usually  deferred 
until  the  end  of  the  operation,  these  vessels  being  divided  and  entrusted  to 
a  reliable,  fine-pointed  clamp  in  the  early  stage  of  the  operation. 

The  difficulty,  the  cost  and  the  infeasibility  of  keeping  on  hand  a  large 
supply  of  needles  threaded  with  catgut,  as  well  as  the  size  of  the  gut,  almost 
preclude  the  extensive  use  of  this  material  for  the  control  of  haemorrhage 
by  transfixion. 

That  surgeons  obtained  excellent  results  with  silk  even  when  gloves  were 
not  worn  one  may  convince  himself  by  the  papers  of  Kocher,2  Heidenhain ' 
and  Hagler.10  Now  that  rubber  gloves  are  invariably  worn,  the  results  with 
silk,  properly  employed,  are  so  perfect  that  I  believe  its  adoption  will  ulti- 
mately become  general. 

9  Heidenhain:  Centralbl.  f.  Chir.,  1899,  No.  26,  p.  225. 

10  Hagler:  Ibid.,  1899,  No.  5,  p.  132. 

4 


34  SUKGICAL  TECHNIC 

A  few  days  ago,  seeing  a  surgeon  of  eminence  and  unusual  fairness  of 
mind  burying  sutures  of  catgut  I  inquired,  "  Why  do  you  still  employ 
catgut?" 

"  Because  I  cannot  free  myself  of  the  prejudice  against  a  nonabsorbable 
suture.  I  believe,"  said  he,  "  that  it  is  foolish  to  use  catgut ;  and  every  now 
and  then  when  my  wounds  break  down  too  frequently  I  discard  it." 

The  catgut  with  which  he  was  sewing  was  No.  2  chromicized;  it  was 
guaranteed  by  America's  most  reliable  firm  "  not  to  absorb  "  for  twenty- 
six  days,  but  not  guaranteed  "  to  absorb  "  within  as  many  weeks. 

It  should  be  borne  in  mind  that  during  the  greater  part  of  the  period  of 
its  disintegration  the  catgut  suture  is  not  only  not  serving  its  purpose  but 
is  playing  the  role  of  necrotic  tissue,  of  a  culture  medium.  I  trust  that  I 
shall  not  be  considered  flippant  in  suggesting  that  the  ideal  absorbable 
suture-material  might  be  a  thread  which  would  serve  its  purpose  for,  say, 
ten  days  and  be  absorbed  in  two  or  three. 

Conceded  that  infection  is  less  likely  to  occur  with  silk  than  with  catgut, 
it  would  still  be  objected,  and  quite  pertinently,  that,  in  case  it  should 
occur,  the  buried  silk  might  give  endless  trouble  and  have  to  be  removed. 

It  is  well  within  reason  to  expect  that  the  technic  may  be  at  least  so  per- 
fect when  silk  is  emploj'ed  that  the  wound  will  become  infected  not  once 
in  a  hundred  cases.  If  fine  silk  were  used  and  the  infection  slight,  prob- 
ably none  of  the  buried  threads  would  be  extruded,  nor  would  healing  be 
delaj'ed  demonstrably  on  account  of  their  presence.  "When  heavy  silk  has 
been  used  for  any  of  the  sutures  and  the  suppuration  is  considerable,  one  or 
more  or,  perhaps,  all  of  the  threads  would  have  to  be  removed.  Even  in 
such  case  it  is  very  unlikely  that  the  ligatures  and  fine  sutures  would  give 
trouble. 

The  Clamp  Twist  in  the  Control  of  the  Haemorrhage 

A  vessel  or  bleeding  point  inaccurately  caught  by  the  artery  clamps  and 
requiring  immediate  ligation  for  any  reasons  may,  as  is  undoubtedly  well 
known,  often  be  controlled  by  a  half -twist  or  slight  rotation  of  the  clamp. 
The  precise  situation  of  the  vessel  may  then  be  determined  by  cautiously 
untwisting  the  instrument  to  the  degree  necessary  to  permit  the  escape  of 
a  fraction  of  a  drop  of  blood  and  then  retwisting.  Now,  instead  of  remov- 
ing the  clamp  and  trying  again  to  catch  the  vessel  in  a  field  which  might 
be  more  or  less  obscured  by  haemorrhage,  one  transfixes  in  a  dry  field  at 
the  proper  place  and  ties  on  one  or  both  sides  of  the  forceps ;  or  if  there  is 
indication  and  room  for  two  clamps,  a  second  may  be  applied  when  the 
exact  situation  of  the  bleeding  point  has  been  revealed  by  the  untwisting 
of  the  first. 


SURGICAL  TECHNIC  35 

The  surgeon  can  transfix  accurately  with  one  hand  while  he  holds  the 
clamp  in  the  other,  and,  by  pulling  on  the  twice  transfixing  thread,  check 
the  haemorrhage  before  tying.  The  bleeding  being  arrested,  both  hands 
are  free  for  making  the  knot. 

The  Interrupted  Stitch 

We  find  ourselves  using  the  interrupted  variety  of  suture  even  more 
frequently  than  formerly.  It  is  more  accurate,  reliable  and  convenient  than 
the  running  stitch,  and,  with  the  long  straight  needles  armed  and  con- 
veniently arranged  as  I  have  described,  can  be  taken  about  as  quickly  as 
the  latter.  The  head  nurse  of  the  operating-room  hands  the  threaded 
needles  to  the  surgeon,  presenting  them  to  him  pointward.  The  operator 
can  take  a  stitch  in  the  time  required  by  the  nurse  to  withdraw  the  next 
needle  and  thread  from  the  cloth  in  which  they  have  been  basted.  The 
knots  are  tied  after  all  the  stitches  have  been  taken.  With  the  aid  of  a 
good  assistant  very  little  time  is  consumed  in  the  tying.  A  granny  knot  is 
adequate  when  fine  silk  is  used.  In  some  instances  the  granny  is  better 
than  the  reef  knot,  for  in  the  tying  of  the  former  in  the  presence  of  tension 
the  traction  on  the  first  turn  of  the  knot  can  easily  be  maintained,  and 
should  the  first  turn  loosen,  in  the  taking  of  the  second  the  slack  can  usually 
be  taken  up  in  the  drawing  home  of  the  latter. 

Undrained  Wounds 

Fine  silk  frequently  enables  one  to  close  a  wound  which  would  have  to  be 
drained  if  catgut  were  employed.  Bleeding  points  so  fine  as  to  be  awk- 
wardly or  not  at  all  ligable  with  catgut  may  be  readily  and  quickly  con- 
trolled by  a  transfixing  suture  of  the  finest  silk  tied  sometimes  with  merely 
a  half  knot.  When  the  ends  of  such  a  knot  are  cut  very  short  the  silk  is 
barely  visible. 

I  am  taking  for  granted  it  will  be  conceded  that  unless  the  haemostasis 
is  quite  perfect  and  the  likelihood  of  bleeding  after  closure  of  the  wound 
negligible,  drainage  should  usually  be  resorted  to.  Unfortunately  catgut 
as  material  for  ligature  does  not  afford  the  security  from  haemorrhage  that 
silk  does,  partly  because  its  knots  are  not  so  dependable  and  partly  because, 
as  I  have  said,  the  former  cannot  so  conveniently  or  so  universally  be  re- 
sorted to  for  transfixion  as  the  latter. 

Faulty  Techxic 

The  surgeon  who  desires  to  use  silk  and  who,  after  giving  it  a  fair  trial, 
finds  that  his  results  are  not  so  good  as  with  catgut  may,  I  think,  quite 


36  SURGICAL  TECHNIC 

surely  attribute  his  failure  to  himself — to  faulty  technic.  By  faulty  technic 
I  do  not  mean  merely  breaks  in  asepsis. 

One  should  not  of  course  use  silk  for  ligating  or  suturing  in  the  presence 
of  infection.  Nor  should  one  bring  parts  together  under  such  degree  of  ten- 
sion as  to  cause  necrosis  or  interfere  greatly  with  the  blood-supply,  for 
nothing  is  gained  by  so  doing  and  decided  harm  may  result.  Healing  is 
menaced  when  the  circulation  of  the  tissues  to  be  united  is  impaired.11 

In  operations  made  through  healing  tissues  catgut  may  occasionally  be 
used  in  preference  to  silk. 

The  silk  employed  should  never  be  coarser  than  necessary  and  it  is  well 
to  employ  for  suture  a  thread  which  is  not  stronger  than  the  tissue  itself. 
A  greater  number  of  fine  stitches  is  better,  as  a  rule,  than  a  few  coarse  ones. 

Avoid,  if  possible,  the  combined  use  of  silk  and  catgut  in  a  wound. 

For  sewing  up  an  abdominal  wound,  when  it  is  necessary  here  and  there 
to  take  heavy  deep  stitches  perforating  skin  and  muscles,  silver  wire  serves 
admirably.  When  the  skin  can  be  approximated  without  tension  we  usually 
employ  interrupted  perforating  stitches  of  very  fine  silk.  If  the  skin-edges 
have  to  be  brought  together  under  considerable  tension  we  recommend  a 
subcuticular  stitch  of  silver  wire  taken  with  the  Hagedorn  or  Schnotter  n 
needle. 

I  have  presented  this  matter  in  such  detail  because  so  many  have  tried 
with  indifferent  or  worse  than  indifferent  success  to  substitute  silk  for 
catgut,  and  because  I  am  told,  as  I  have  said,  that  the  operators  and  pupils 
of  the  surgical  clinic  of  The  Johns  Hopkins  University  are  quite  the  only 
ones  in  this  country  who  systematically  employ  the  former. 

I  believe  that  the  tendency  will  always  be  in  the  direction  of  exercising 
greater  care  and  refinement  in  operating,  and  that  the  surgeon  will  develop 
increasingly  a  respect  for  tissues,  a  sense  which  recoils  from  inflicting 
unnecessary  insult  to  structures  concerned  in  the  process  of  repair. 

The  Epithelial  Stitch 

In  the  toilet  of  wounds  in  animals  we  meet  conditions  different  in  some 
respects  from  those  which  obtain  in  the  human  subject.  The  long  hair,  the 
deep  follicles  of  the  skin  of  dogs  and  the  inconveniences  incident  to  sub- 

II  In  operations  for  the  oblique  as  well  as  the  direct  form  of  inguinal  hernia  we 
sometimes  split  vertically  the  sheath  of  the  rectus  muscle  for  the  relief  of  strain  on 
the  stitches  holding  together  the  internal  oblique  muscle  or  conjoined  tendon  and 
Poupart'8  ligament. 

"It  is  known  only  to  a  few  surgeons  that  the  late  Dr.  Schnotter,  surgeon  to  the 
German  Hospital,  New  York,  devised  and  used  the  needle  curved  on  the  edge  some 
years  before  Hagedorn  described  it. 


SURGICAL  TECHXIC  37 

sequent  dressings  make  it  desirable  to  modify  the  technic  of  closing  the 
wounds  in  these  animals. 

Stitching  of  the  platysma  muscle  does  not  hold  together  sufficiently  well 
the  edges  of  the  skin,  and  the  subcuticular  stitch  taken  close  to  the  incised 
border  is  not  so  safe  in  the  dog  as  in  the  human  subject  because  the  follicles 
are  relatively  deeper  and  more  numerous  in  the  former.  Hence,,  in  the  dog, 
after  suturing  the  platysma  we  place  a  running  subcuticular  suture  a  little 
further  than  usual  from  the  free  edge  of  the  skin.  Should  now  the  approxi- 
mation of  the  skin  not  be  sufficiently  perfect  we  add  the  "  epithelial  stitch." 
This  is  made  with  silk  about  00  fine  and  with  a  needle  to  correspond. 
Hardly  more  than  the  epithelium  is  pierced  by  the  needle,  and  the  suture 
when  completed  describes  almost  a  straight  line  (Plate  II,  3).  The  epi- 
thelial stitch  produces  no  irritation  and  does  not  require  subsequent  atten- 
tion, for  it  rubs  off  in  the  ordinary  process  of  attrition,  or  it  may  be  pulled 
off  at  any  time  like  a  plaster.  Inasmuch  as,  in  dogs,  stitches  which  pierce 
the  skin  should  be  removed  in  two  or  three  days  lest  the  infection  which 
they  cause  give  rise  to  suppuration,  and  as  it  is  undesirable  and  trouble- 
some in  the  case  of  animals  to  remove  stitches  or  to  expose  the  wound  so 
soon  after  operation,  stitching  in  some  such  way  as  above  described  has 
decided  advantages. 

Celloidix-Batiste 

In  many  of  our  operations,  and  always  when  it  seems  particularly  indi- 
cated, we  paste  to  the  skin  over  a  wide  field  a  fine  batiste  (sometimes  gauze, 
or  silk)  dipped  in  celloidin. 

In  amputations  at  or  near  the  hip-joint,  the  actual  field  of  operation  may 
or  may  not  be  covered  with  the  cambric.  A  liberal  flounce-like  sheet  pasted 
along  the  side  of  the  genitals  from  pubes  to  sacrum,  along  Poupart's  liga- 
ment and  from  the  anterior  superior  spine  of  the  ilium  along  the  outer  side 
of  the  thigh  to  the  tuberosity  of  the  ischium,  in  other  words  a  truncated 
hollow  cone  which  encircles  the  thigh  just  above  the  line  of  amputation, 
suffices.  This  flounce  should  extend  well  up  on  to  the  abdomen  and  back 
and  side,  and  down  on  the  inside  of  the  opposite  thigh. 

Gloves 

Rubber  gloves  must,  of  course,  be  worn  by  all  concerned  in  the  operation. 

In  a  letter  of  a  few  weeks  ago  the  director  of  a  famous  German  clinic 
asked  me  to  give  him  references  to  articles  that  I  might  have  written  on 
the  subject  of  rubber  gloves.  As  response  to  his  request  and  believing  that 
a  brief  account  concerning  the  introduction  of  gloves  may  eventually  be  of 
interest  I  will,  in  as  few  words  as  possible,  relate  the  story. 


38  SURGICAL  TECHXIC 

In  the  winter  of  1889  and  1890 — I  cannot  recall  the  month — the  nurse 
in  charge  of  my  operating-room  complained  that  the  solutions  of  mercuric 
chlorid  produced  a  dermatitis  of  her  arms  and  hands.  As  she  was  an  un- 
usually efficient  woman,  I  gave  the  matter  my  consideration  and  one  day 
in  Xew  York  requested  the  Goodyear  Rubber  Company  to  make  as  an 
experiment  two  pair  of  thin  rubber  gloves  with  gauntlets.  On  trial  these 
proved  to  be  so  satisfactory  that  additional  gloves  were  ordered.  In  the 
autumn,  on  my  return  to  town,  the  assistant  who  passed  the  instruments 
and  threaded  the  needles  was  also  provided  with  rubber  gloves  to  wear  at 
the  operations.  At  first  the  operator  wore  them  only  when  exploratory  inci- 
sions into  joints  were  made.  After  a  time  the  assistants  became  so  accus- 
tomed to  working  in  gloves  that  they  also  wore  them  as  operators  and  would 
remark  that  they  seemed  to  be  less  expert  with  the  bare  hands  than  with 
the  gloved  hands. 

I  think  it  was  Dr.  Bloodgood,  my  house  surgeon,  who  first  made  this 
comment  and  that  he  was  the  first  to  wear  them,  invariably,  when  operating. 

In  the  report  u  which  I  made  of  the  first  year's  work  at  the  hospital, 
written  in  November  and  December,  1890,  and  published  in  March,  1891, 
I  stated  that  the  assistant  who  passed  the  instruments  wore  rubber  gloves. 
This  assistant  was  given  the  gloves  to  protect  his  hands  from  the  solution 
of  phenol  (carbolic  acid)  in  which  the  instruments  were  submerged  rather 
than  to  eliminate  him  as  a  source  of  infection.  I  do  not  recall  having  re- 
ferred again,  in  my  publications,  to  the  employment  of  rubber  gloves. 
Dr.  Hunter  Robb  in  1894,  in  his  book  on  aseptic  technic  "  recommended 
that  the  operator  wear  rubber  gloves.  Dr.  Robb  was,  at  that  time,  resident 
gynaecologist  of  The  Johns  Hopkins  Hospital  and  had  frequent  oppor- 
tunities to  observe  the  technic  of  the  surgical  clinic. 

This  incidental  reference  by  Robb  in  1894  to  the  wearing  of  rubber  gloves, 
and  the  fact  that  a  photograph  of  an  operation  for  breast  cancer  taken  late 
in  the  year  1S93  shows  that  gloves  were  not  being  regularly  worn  by  us  at 
that  time,  serve  to  establish  approximately  the  date  of  their  definite 
introduction. 

Dr.  Joseph  C.  Bloodgood,  in  his  elaborate  report  u  on  Hernia  makes  the 
following  statements  with  reference  to  the  wearing  of  gloves : 

"  The  writer  was  the  first  as  operator  to  wear  gloves  as  a  routine  practice 
in  practically  all  clean  operations.  He  began  to  wear  gloves  invariably  in 
December,  1896 ;  before  this  date  he  had  operated  in  twenty  cases  of  hernia 

"Johns  Hopkins  Hosp.  Rep.r  iv,  No.  6,  plate  xii. 
14  Robb,  Hunter:  Aseptic  Surgical  Technic. 

"Johns  Hopkins  Hosp.  Rep..  Bait.,  1SS9,  vii.  Operations  on  459  cases  of  hernia  in 
The  Johns  Hopkins  Hospital  from  June,  18S9,  to  January,  1S99. 


SURGICAL  TECHNIC  39 

with  four  suppurations,  all  late  infections ;  wounds  were  closed  with  silver 
wire.  Since  wearing  gloves  he  has  operated  in  100  cases  of  inguinal  hernia. 
In  one  case  (recent)  the  wound  suppurated. 

"  Rubber  gloves  were  introduced  by  Professor  Halsted  soon  after  the 
hospital  opened  in  1889.  They  were  invariably  worn  by  the  assistant  who 
handed  instruments  and  by  the  assistant  at  the  wound,  usually  the  nurse  in 
charge  of  the  operating-room.  The  operator  himself  rarely  wore  gloves 
(at  that  time)1"  except  when  clean  joints  were  opened." 

Thus  the  operating  in  gloves  was  an  evolution  rather  than  an  inspiration 
or  happy  thought,  and  it  is  remarkable  that  during  the  four  or  five  years 
when  as  operator  I  wore  them  only  occasionally,  we  could  have  been  so 
blind  as  not  to  have  perceived  the  necessity  for  wearing  them  invariably  at 
the  operating-table. 

It  is  also  noteworthy  that  none  of  the  many  surgeons,  foreign  and  Ameri- 
can, who  visited  our  clinic  in  those  years  should  have  recognized  the  desira- 
bility of  eliminating  the  hands  as  a  source  of  infection,  by  the  wearing  of 
gloves. 

We  did  not  realize  how  slightly  the  sense  of  touch  is  obtunded  by  the 
rubber  covering,"  or  how  unessential  it  is  in  most  operations  that  the  great- 
est delicacy  of  finger  perception  be  preserved.  Furthermore  we  were  de- 
lighted with  the  results  in  healing  already  obtainable,  so  vivid  were  the 
memories  of  infections  in  the  recent  past. 

Silver  Foil 

Since  1894 18  we  have  covered  our  fresh  wounds  with  silver  foil  and  are 
quite  convinced  that  this  dressing  has  appreciable  chemical  as  well  as 
physical  values. 

That  various  metals  inhibit  the  growth  of  certain  organisms  had  been 
proved  by  Miller,1*  N/ageli/0  Behring,n  Uffelman,"  Meade  Bolton"  and 
others. 

16  Italicized  words  mine. 

17  For  example,  in  the  early  days  of  rubber  gloves  I  removed  the  glove  from  one 
hand,  not  infrequently,  to  palpate  the  common  bile-duct  in  search  for  stone. 

"Halsted:    Am.  Jour.  Med.  Sc,  July,  1895. 

19  Miller:  Demonstration  einer  Methode  zur  Bestimmung  der  antiseptischen  Eigen- 
schaften  von  Zahnfiillungsmitteln,  Verhandl.  d.  deutsch.  odont.  Gesellsch.,  1889,  i,  34. 

M  Niigeli,  C.  von :  Ueber  oligodynamische  Erscheinungen  in  lebenden  Zellen. 
Denkschr.  d.  schweiz.  naturforsch.  Gesellsch.,  1893,  xxxiii,  1.  See  also  review  in  Bot. 
Centralbl.,  Iv,  93. 

21  Behring:   Ztschr.  f.  Hyg.,  1890,  ix,  482. 

13  Uff elman :  Beitrage  zur  Biologie  des  Cholerabacillus,  Berl.  klin.  Wchnschr.,  1892, 
No.  48,  p.  1212. 

23  Tr.  Assn.  Am.  Phys.,  1894,  p.  174. 


40  SURGICAL  TECHNIC 

Bolton's  work  interested  me  particularly  because  very  kindly,  in  our 
behalf,  he  tested  thoroughly  the  effect  of  silver  on  the  growth  of  the  com- 
mon pyogenic  microorganisms.  For  his  experiments  he  used  silver  in  vari- 
ous forms  but  particularly  the  silver  foil  with  which  we  were  at  the  time 
covering  our  wounds. 

I  had  previously  employed  foils  of  copper,  brass,  gold  and  aluminum  and 
had  found  that  copper  and  brass  irritated  the  skin.  The  silver  foil  had 
given,  clinically,  the  most  satisfactory  results  and  I  was  pleased  to  find 
that  its  use  had  the  support  of  Bolton's  carefully  conducted  experiments. 
The  admirable  behavior  of  wire  in  wounds  which  has  been  commented  on 
for  centuries  may,  therefore,  be  attributed  to  its  antiseptic  properties. 

Under  the  foil  the  stitches  which  perforate  the  skin  may,  it  seems'  to  me, 
be  left  undisturbed  for  a  greater  number  of  days  than  under  the  ordinary 
dressings.  Thiersch  grafts  implanted  on  clean  fresh  surfaces  and  covered 
with  silver  foil  need  not  be  investigated  for  ten  days  or  more.  The  foil, 
while  it  seals  the  dry  wound  hermetically,  readily  permits  the  escape  of 
fluids. 

We  may,  possibly,  overestimate  the  value  of  silver  foil  as  a  dressing,  but 
we  are  wedded  to  its  use,  and  I  know  of  nothing  which  could  quite  take  its 
place,  nor  have  I  known  any  one  to  abandon  it  who  had  thoroughly  familiar- 
ized himself  with  the  technic  of  its  employment.  Moistening  the  skin  and 
the  applied  foil  with  alcohol  facilitates  its  application,  but  alcohol  should 
not  be  employed  in  the  laying  on  of  the  foil  over  skin-grafts. 

Three  or  four  layers  of  foil  are  usually  placed  on  the  closed  incision,  and 
over  these  is  laid  the  thin  paper  between  the  leaves  of  which  the  foil  is 
packed.  We  have  occasionally  covered  the  foil  with  strips  of  very  thin, 
bibulous,  Japanese  paper.  Foil  without  paper  and  covered  with  crepe  lisse 
and  celloidin  makes  a  particularly  neat  dressing  for  wounds  of  the  face 
and  scalp. 

Gutta-Percha  Tissue 

Dr.  Jacob  Frank,24  in  an  interesting  account  of  the  discovery  of  gutta- 
percha and  the  uses  of  gutta-percha  tissue  in  surgery  stated  that  perhaps 
the  first  mention  of  this  tissue  is  to  be  found  appended  to  a  report  on  gutta- 
percha submitted  to  the  Academie  de  medecine,  July  30,  1850,  by  a  com- 
mission composed  of  Messrs.  Chevallier,  Poiseuille  and  Robert.  Consulting 
this  report,  I  find  that  it  was  called  tissu  electro-mag netique,  approved  by 
the  National  Academy  of  Medicine,  tested  in  the  various  hospitals  in  Paris, 
and  recommended  as  a  sovereign  remedy  for  gout,  rheumatism,  sciatica, 

"Frank,  Jacob:  Gutta-Percha  Tissue  in  Surgery,  The  Journal  A.  M.  A.,  March  19, 
1910,  p.  942. 


SURGICAL  TECHNIC  41 

migraines,  neuralgias  and  gastralgias,  for  the  resolution  of  varices,  for  the 
dressing  of  wounds,  burns,  etc. ;  also  for  pneumonia  in  its  early  stages.  The 
tissue  was  relatively  thick;  it  could  be  washed  and  used  indefinitely,  and 
was  represented  as  being  greatly  superior  to  the  medicated  oiled  papers 
which  were  not  only  inert  but  soiled  the  body  and  the  linen  and  were  alto- 
gether disagreeable  in  use.  "  To  convince  oneself  of  its  magnetic  properties, 
one  had  merely  to  rub  it  lightly  on  a  piece  of  cloth  and  hold  it  above  saw- 
dust. Instantly  particles  of  the  sawdust  would  spring  up  and  attach  them- 
selves to  the  tissue." 

In  the  light  of  our  experience  with  the  gutta-percha  tissue  of  the  present 
day  we  can  well  believe  that  the  tissu  electro-magnetique  was  really  service- 
able at  times  in  the  treatment  of  the  affections  enumerated.  Its  disuse  may 
have  been  due  in  part  to  its  pseudonym. 

Dr.  Manoury,25  six  years  later,  recommended  medicated  plaques 26  of 
gutta-percha. 

"  To  apply  a  plaque  one  dips  it  in  warm  water,  40  degrees,  in  order  that 
it  may  conform  by  its  flexibility  to  the  protuberances  and  anfractuosities  of 
the  ulcer ;  when  it  has  been  applied  one  covers  it  with  a  cloth  wet  with  cold 
water,  with  view  to  preventing  the  adhesions  of  this  cloth  to  the  external 
surface  of  the  plaque." 

A.  Cousin  "in  1872  wrote  as  follows : 

"  Gutta-percha,  on  account  of  its  numerous  and  valuable  properties,  has 
for  a  long  time  attracted  the  attention  of  practitioners  of  medicine  and 
surgery,  and  on  consulting  the  instructive  collection  of  the  Bulletin  de 
therapeutique  one  finds  not  less  than  twenty-three  papers  devoted  to  the 
consideration  of  the  diverse  uses  of  this  substance. 

"  It  has  been  employed,  in  the  solid  state,  in  the  fabrication  of  apparatus 
for  fractures,  of  caustic  pastes,  of  sounds  and  bougies,  of  protheses,  of  vari- 
ous utensils;  dissolved  in  chloroform  it  was  at  one  time  much  vaunted  in 
the  topical  treatment  of  certain  skin  affections  as  substitute  for  collodion. 

"  Every  one  knows  today  the  excellent  results  obtained  by  the  occlusive 
method  in  the  treatment  of  a  great  number  of  medical  and  surgical  affec- 
tions (occlusive  dressings,  compressing  or  contracting,  of  collodion,  swath- 
ing in  impermeable  cloths,  pneumatic  occlusion,  wadded  splints,  etc.).  It 
would  take  too  long  to  study,  comparatively,  the  indications  for  the  various 
dressings  or  the  advantages  and  defects  that  they  present ;  I  wish  simply  to 

25  Manoury,  A. :  Des  plaques  de  gutta-percha  medicamenteuses  et  leur  applications, 
Bull.  gen.  de  therap.  med.  et  chir.,  1856,  vol.  1. 

26  a.  Plaques  de  gutta-percha  et  de  hmaille  de  fer  porphyrisee.  b.  Plaques  vesicantes 
composes  de  gutta-percha  et  de  cantharides.  c.  Caustique  fluidifiant  (gutta-percha  and 
potassium),    d.  Caustique  coagulant    (gutta-percha   and  chlorid  of  zinc). 

2T  Cousin,  A. :  Sur  l'emploi  de  la  gutta-percha  laminee  comme  agent  d'occlusion,  Bull, 
gen.  de  therap.  med.  et  chir.,  1872,  lxxxii. 


42  SURGICAL  TECHNIC 

make  known  to  the  readers  of  the  Bulletin  a  method  which  I  believe  to  be 
new  and  which  is  assuredly  a  simple  and  easy  one  for  making  occlusion. 

"  I  employ  for  this  purpose  leaves  of  gutta-percha  reduced  by  rolling  to 
the  thinness  of  waxed  taffeta,  and  I  take  advantage  of  its  extreme  solubility 
in  chloroform  to  give  to  this  material  adhesive  qualities  of  considerable 
degree. 

"  I  proceed  in  the  following  manner :  Given  a  surface  of  skin  to  be  cov- 
ered, I  cut  a  piece  of  flattened  gutta-percha  to  dimensions  two  or  three 
times  as  large  as  this  area ;  I  trace  along  the  border  of  this  variety  of  plas- 
ter, for  an  extent  of  1  or  2  cm.,  a  brush  dipped  in  chloroform  and  apply  it 
immediately  to  the  skin ;  adhesion  takes  place  with  great  energy  at  all  the 
points  touched  by  the  chloroform,  and  so  perfectly  that  the  slightest  irregu- 
larities of  the  skin  are  reproduced  with  remarkable  fidelity  in  the  imperme- 
able material." 

I  have  quoted  at  such  length  from  the  article  of  Dr.  Cousin  in  order  to 
make  clear  what  were  the  uses  which  had  been  made  of  gutta-percha  tissue 
to  the  year  1872,  and  because  it  may  be  interesting  to  others  to  read  the 
original  description  of  a  clever  and  useful  procedure — the  pasting  of  the 
edges  of  a  leaf  of  gutta-percha  to  the  skin  by  means  of  chloroform. 

Occasionally  we  paste  with  chloroform  a  small  scrap  of  gutta-percha 
tissue  to  a  piece  of  old  linen  when  the  skin  surrounding  the  granulating 
surface  which  is  to  be  covered  with  gutta-percha  tissue  is  likely  to  become 
irritated  by  the  discharges  from  the  ulcer.  In  such  case  the  protective  is 
cut  to  the  precise  size  of  sore,  the  skin  about  which  being  covered  with  an 
ointment  of  zinc  oxid;  the  discharges  are  promptly  absorbed  by  the  linen 
and  overlaid  dressings.  It  is  well,  under  these  conditions,  to  cut  a  tiny  hole 
through  both  protective  and  linen  to  permit  the  prompt  escape  of  the  secre- 
tions of  the  wound  into  the  dressing. 

Dr.  Frank  gave  two  references  "•  "  to  the  early  employment  by  physicians 
of  plaques  or  "  sheets  "  of  gutta-percha,  but  was  unable  to  make  any  state- 
ment relative  to  its  introduction  in  its  present  form  and  for  its  present 
purposes,  and  leaves  unfilled  a  gap  of  perhaps  a  quarter  of  a  century. 

As  I  know  of  no  one  except  myself  who  can  tell  the  story,  I  may  be  par- 
doned for  a  moment's  indulgence  in  reminiscence. 

As  interne  of  Bellevue  Hospital,  New  York,  from  1876  to  1878  I  had 
frequent  opportunities  to  observe  the  pain  and  bleeding  incident  to  the 
tearing  out  of  gauze  from  large  involucral  cavities  after  sequestrotomy — 
gauze  which  had  been  stuffed  into  these  cavities  to  arrest  bleeding  and  into 
which  the  granulations  had  grown,  often  for  a  considerable  distance. 
Wounds  of  the  soft  parts  would  also  be  packed  with  gauze,  which  from  its 
adhesion  to  the  skin  would  cause  pain,  sometimes  very  distressing,  and  the 
first  removal  of  the  gauze  was  an  event  anticipated  with  apprehension  by 


SURGICAL  TECHNIC  43 

the  patients,  who  were  quite  sure  to  be  advised  by  their  ward-neighbors  of 
its  terrors. 

During  the  two  years  of  my  study  abroad  the  desirability  of  obviating 
this  rather  barbarous  practice  was  repeatedly  enforced  on  me  by  what  I 
saw  in  the  foreign  clinics,  and  on  my  return  to  America  in  1880  I  promptly 
cast  about  for  some  sort  of  protective,  non-adhering  dressing.  Oiled  silk 
and  the  green  protective  of  Lister  were  not  sufficiently  pliable.  Finally  a 
salesman  in  one  of  the  surgical  supply  stores  showed  me  a  bed-sheet  of 
gutta-percha  as  heavy  as  blotting-paper,  remarking  that  it  could  be  rolled 
out  to  any  degree  of  thinness.  I  requested  him  to  procure  the  thinnest  tissue 
possible,  and  in  the  course  of  a  few  weeks  he  provided  me  with  samples, 
none  of  which  was  sufficiently  thin.  After  a  month  or  two  tissue  of  the 
desired  thinness  was  obtained  and  from  that  day  until  the  present,  a  period 
of  nearly  thirty-three  years,  gutta-percha  tissue,  usually  referred  to  as  rub- 
ber tissue  or  protective,  has  been  one  of  the  most  prized  and  indispensable 
articles  of  my  surgical  armamentarium.28 

Accounts  of  the  first  emplojonent  of  gutta-percha  tissue  to  protect  granu- 
lations from  insult  and  to  prevent  them  from  growing  into  or  adhering  to 
drains,  gauze  packs  and  dressings  and  to  promote  healing  under  a  moist 
scab  can  probably  be  found  in  the  records  of  the  Roosevelt  Hospital  Dispen- 
sary, New  York,  from  1881  to  1886,  the  term  of  my  incumbency  as  director 
of  this  dispensary;  and  some  of  my  assistants  and  students  of  those  years 
will  doubtless  recall  having  employed  it  there  as  a  dressing  for  wounds. 

I  have  not  searched  for  references  to  the  use  of  gutta-percha  tissue  in  its 
present  form  and  for  its  present  purposes  subsequent  to  the  time  of  its 
introduction  in  1881,  but  I  am  quite  sure  that  no  mention  of  it  will  be  found 
prior  to  1884  or  1885,  and  that  should  there  be  any  such  it  will  have  been 
made  by  surgeons  of  New  York  who  might  have  learned  of  it  from  my 
students  or  seen  it  employed  at  one  of  the  various  hospitals  with  which, 
as  attending  surgeon,  I  was  connected. 

Its  employment  as  drainage  material  for  the  abdominal  cavity  came 
about  as  follows : 

At  first  we  tucked  it  about  the  gauze  drains  at  the  surface  only,  in  order 
to  prevent  adhesions  to  the  skin.  Then  the  protective  was  carried  deeper 
and  deeper  into  the  wounds  until  finally  the  entire  gauze  drain  or  gauze 
pack,  except  at  the  very  bottom,  was  enveloped  in  the  gutta-percha  tissue. 

The  experiments  of  Dr.  Yates  of  my  staff,  made  to  determine  the  amount 
of  time  required  for  the  formation  about  the  protective  of  intestinal  ad- 
hesions, were  especially  important  and  had  their  influence  in  emboldening 

28  Brief  reference  to  the  use  of  gutta-percha  tissue  is  made  in  Johns  Hopkins  Hosp. 
Rep.,  ii,  No.  5,  p.  306. 


44  SURGICAL  TECHNIC 

the  surgeon  at  times  to  dispense  altogether  with  the  gauze,  placing  his 
reliance  on  the  gutta-percha. 

Not  very  often  do  we  venture  to  drain  an  abdominal  wound  with  nothing 
but  protective.  Usually  the  cigarette  form  of  drain  is  employed — gauze 
enveloped  in  protective — when  we  wish  to  know  that  a  drain  is  precisely 
and  promptly  fixed  in  the  desired  position,  as  it  is  by  the  little  tuft  of  gauze 
at  the  bottom  of  the  cigarette. 

For  certain  cases  in  which  it  seems  desirable  that  adhesions  should  form 
more  rapidly  and  firmly  about  the  abdominal  drain  we  make  it  as  follows : 
Two  squares,  one  of  gauze  (single  sheet)  and  one  of  protective,  are  rolled 
together,  the  gauze  outside,  until  a  drain  of  the  desired  thickness  is  obtained. 
Granulations  cannot  pierce  this  drain  deeper  than  the  single  layer  of  gauze, 
because  they  at  once  encounter  the  underlying  protective.  Such  a  drain  is 
removed  quite  as  easily  as  the  cigarette  drain  and  offers  a  little  more 
security  than  the  latter. 

A  moist  scab,  so-called,  is  better  than  a  dry  one.  The  surgeon  has  many 
opportunities  to  convince  himself  of  this.  When  he  has  occasion  to  extract 
a  toe-nail  let  him  cover  one-third  of  the  raw  surface  with  protective  and 
allow  the  remainder  to  heal  under  the  dry  scab.  The  patient  may  have  pain 
in  the  digit  soon  after  the  dry  scab  is  well  formed,  and  the  surgeon  will 
perhaps  observe  that  the  soft  parts  about  the  nail-bed  on  the  side  of  the 
dry  scab  are  inflamed.  On  covering  the  entire  surface  of  the  granulating 
wound  with  gutta-percha  tissue  the  pain  will  promptly  be  relieved  and  the 
inflammation  subside. 

The  dry  scab  imprisons  secretion  which  in  turn  gives  rise  to  tension,  and 
the  tension  impairs  the  vitality  of  the  tissues  under  and  at  the  border  of 
the  dry  scab  to  an  extent  sufficient  to  place  them  at  a  disadvantage  in  their 
combat  with  the  microorganisms,  and  to  compel  absorption  of  the  toxins. 

Even  pimples  and  trivial  wounds  of,  for  example,  the  fingers  behave  best 
under  the  moist  scab.  For  the  healing  of  wounds  under  the  moist  blood- 
clot,  particularly  when  the  skin  cannot  be  made  to  cover  the  cavity  to  be 
filled  with  blood,  gutta-percha  tissue  is  invaluable.  It  would  be  found 
useful  in  every  household  and  should  be  included  in  the  supplies  provided 
for  first  aid  to  the  injured.  The  value  of  the  moist  scab  should  be  common 
knowledge  for  the  layman,  and  gutta-percha  tissue  should  replace  for  him 
the  sticking-plaster  as  a  covering  for  wounds. 

A  few  months  ago  in  reading  one  of  Lister's  *  first  papers  on  the  use  of 
phenol  in  wounds  I  noted  that  he  mentions  having  covered  a  wound  with 
a  tissue  of  gutta-percha.  This  interested  me  so  much  that  I  wrote  at  once 
to  Sir  William  Watson  Cheyne,  being  confident  that  no  one  could  give  me 

20  Lancet,  London,  March  16,  1867,  p.  328. 


SURGICAL  TECHNIC  45 

the  desired  information  so  well  as  he.    From  his  kind  reply  I  quote  as 
follows : 

"  So  far  as  I  understand  the  matter,  Lister  tried  various  materials  to 
cover  the  wound  after  an  operation,  so  as  to  prevent  the  phenol  in  the 
dressing  from  penetrating  in  any  quantity  to  the  wound.  Among  other 
things  he  tried  gutta-percha  tissue,  but  he  abandoned  that  because  the 
phenol  easily  passed  through  it  so  that  it  did  not  protect  the  wound  from 
the  irritation  of  the  antiseptic,  and  the  material  he  ultimately  hit  on  was 
oiled  silk,  covered  with  a  layer  of  dextrin,  so  as  to  allow  it  to  be  wet.  The 
oiled  silk  itself  did  not  prevent  the  phenol  vapor  from  passing  through  it, 
but  the  combination  of  oiled  silk  and  shellac,  according  to  Lister's  experi- 
ments, did.  As  regards  any  question  of  priority  in  using  it,  so  far  as  any 
claim  can  be  advanced  on  Lister's  behalf,  it  would  not  hold,  because  he  tried 
it  and  abandoned  it  as  being  unsuitable  for  his  particular  purpose." 

From  1879  to  1889  I  made  frequent  visits  to  England  and  the  continent 
and  was  in  close  touch  with  the  work  of  the  surgical  clinics  of  England, 
France  and  Germany,  and  not  once  in  that  period  did  I  see  gutta-percha 
tissue  employed  in  Europe. 

It  is  gratifying  to  me  to  observe  the  place  in  surgery  which  gutta-percha 
tissue  has  gradually  won  for  itself.  For  the  American  surgeon  it  has  become 
an  indispensable  appurtenance  of  his  equipment. 


ASEPTIC  SURGERY  IN  NEW  YORK  IN  1884 ' 

Dr.  William  S.  Halsted  thought  that  it  would  be  difficult  in  a  given  case 
to  know  just  what  to  attribute  a  bad  result  to,  with  the  imperfect  antiseptic 
technic  at  present  existing  even  in  our  best  New  York  hospitals.  Trained 
nurses,  with  long  sleeves  and  hands  uninspected,  were  allowed  to  pass  and 
hold  dry  sponges.  He  had  repeatedly  observed  ligatures  handed  to  the 
operator  from  the  mouth  of  the  interne,  and  seldom  failed  to  find  instru- 
ments, especially  artery  clamps,  which  had  been  insufficiently  cleaned.  He 
observed  further  that  in  some  of  the  hospitals  the  preparation  of  the  catgut 
was  intrusted  to  the  apothecary,  and,  even  if  it  was  prepared  by  the  interne 
it  would  not  be  a  guarantee  that  it  was  properly,  even  if  conscientiously, 
done. 

1  Remarks  in  discussion  of  Dr.  Thomas  M.  Markoe's  paper.  "  Recurring  carcinoma  of 
the  arm;  capillary  drainage."  New  York  Surgical  Society,  October  14,  1884.  (These 
brief  remarks  are  included  because  of  their  historical  interest. — Editor.) 

N.  York  M.  J.,  1884,  xl,  497. 

Also:  Med.  News,  Phila.,  1884,  xlv,  495. 


if, 


INCISION  FOR  NEPHRECTOMY ■ 

Dr.  "W.  S.  Halsted  thought  that,  irrespective  of  the  question  of  compara- 
tive risk,  most  surgeons  would  allow  that  neoplasms  of  the  kidney  could 
be  more  satisfactorily  dealt  with  through  the  abdominal  incision.  Certain 
operators,  who  were  complete  masters  of  the  technic  of  abdominal  sur- 
gery, would  be  justified  in  preferring  and  practising  laparotomy  in  the 
removal  of  kidney  tumors,  whereas  the  great  majority  of  surgeons  might 
prefer,  for  the  present,  to  confine  themselves  to  the  lumbar  incision.  Each 
surgeon  should,  therefore,  be  the  conscientious  judge  of  his  own  attitude. 
Thus  it  was  easy  to  comprehend  why  von  Bergmann,  Thornton,  Tait,  and 
others  should  adopt  the  abdominal  incision;  and,  although  Tait  would  not 
confess  the  secret  of  his  success,  it  was  quite  apparent  to  others  that  it  was 
to  be  ascribed  to  operative  skill  and  most  careful  asepsis. 

Dr.  Halsted  was  inclined  to  advocate,  for  the  abdominal  incision,  a  line 
lateral  to  that  recommended  by  Langenbeck,  for  two  reasons:  first,  to 
avoid,  if  possible,  subsequent  hernia,  and,  second,  to  enable  one,  early  in  the 
operation,  to  sew  off  the  operative  field  from  the  general  peritonaeal  cavity. 
It  seemed  to  him  that  the  suggestion  from  Hagen-Torn  ("  Centralbl.  fiir 
Chir.,"  No.  35,  1884)  to  cut  through  the  rectus  abdominus  muscle  rather 
than  through  the  linea  alba,  to  prevent  hernia  after  ovariotomy,  was  a  good 
one.  He  advised  also  that  especial  attention  should  be  paid  to  the  sewing 
of  the  incision  through  the  oblique  and  transverse  abdominal  muscles. 
A  cross-cut  of  such  a  wound  would  give  two  lines,  irregularly  concavo- 
convex,  demonstrating  that  the  various  tissues  had  retracted  unequally, 
and  that,  to  make  the  cut  surfaces  offer  the  broadest  possible  face,  it  would 
be  necessary  to  convert  the  undulating  into  plane  surfaces.  This  could  be 
done  by  one  or  more  rows  of  buried  sutures  aimed  at  the  concavities.  To 
enable  one  to  operate  outside  of  the  peritonaeal  cavity,  Dr.  Halsted  recom- 
mended a  procedure  to  which  he  had  resorted  in  his  case.  The  abdominal 
cavity  was  opened  along  Langenbeck's  line.  In  future  cases  he  would  open 
it  outside  of  this  line,  as  just  described.  In  front  of  the  carcinomatous 
kidney  was  the  descending  colon.  The  parietal  peritonaeum  was  a  second 
time  divided  at  about  three  inches  from  the  outer  border  of  the  colon  and 

1  Remarks  in  discussion  of  Dr.  Robert  F.  Weir's  paper,  "  Extirpation  of  the  kidney." 
New  York  Surgical  Society,  December  9,  1884. 
N.  York  M.  J.,  1884,  xl,  734. 
Also:  Med.  News,  Phila.,  1885,  xlvi,  15. 

47 


48  INCISION  FOE  NEPHRECTOMY 

the  kidney  readily  removed.  The  haemorrhage  from  the  kidney-bed  was 
rather  profuse  from,  perhaps,  about  a  hundred  oozing  points.  This  was 
only  partially  controlled  by  about  as  many  catgut  ligatures.  The  peritonaeal 
cavity  was  then  closed  off  from  the  field  of  operation  by  uniting  the  mesial 
edges  of  the  twice-divided  peritonaeum.2  Thus  an  extraperitoneal  cavity 
was  formed,  bounded  postero-externally  by  the  kidney-bed  and  the  ab- 
dominal paries  which  had  been  robbed  of  its  peritonaeum ;  antero-externally 
by  the  isolated  strip  of  peritonaeum,  the  margins  of  which  were  the  lateral 
edges  of  the  original  parietal  incisions ;  and  internally  by  the  outer  surface  of 
the  somewhat  curtailed  peritonaeal  cavity.  The  extraperitonaeal  cavity  was 
drained  (anteriorly)  by  two  large  rubber  tubes.  The  haemorrhage  stopped 
at  once  from  intestinal  pressure  and  convinced  the  operator  that  he  might 
have  spared  himself  much  trouble  and  the  patient  some  shock,  if,  instead  of 
applying  so  many  ligatures,  he  had  earlier  closed  off  the  peritorjaeal  cavity 
as  described.  The  patient  recovered  rapidly  from  the  shock  of  the  operation 
and  passed  a  comfortable  night.  In  the  morning  he  developed  uraemic  con- 
vulsions, which  recurred  at  intervals  until  his  death,  about  twenty-seven 
hours  after  the  operation.  He  secreted,  in  this  time,  only  an  ounce  and  a 
half  of  urine. 

A  complete  autopsy  was  not  allowed.  Injection  of  the  extraperitonaeal 
cavity  demonstrated  that  the  peritonaeal  cavity  had  been  completely  shut 
off.  In  the  latter  was  about  a  drachm  of  slightly  stained  serum,  but  there 
were  no  other  evidences  of  peritonitis.  Microscopical  examination  revealed 
advanced  interstitial  disease  of  the  right  kidney.  Dr.  Halsted  thought  it 
fair  to  attribute  the  convulsions  to  the  condition  of  the  right  kidney,  for 
the  patient's  pulse  was  too  strong  to  make  it  probable  that  diminished  blood- 
pressure  alone  might  have  been  the  cause  of  the  oliguria. 

2  An  original  procedure. — W.  S.  H. 


A  NEEDLE-HOLDER  FOR  HAGEDORN'S  NEEDLES1 

Of  the  very  many  surgeons  who  use  the  so-called  Hagedorn's  needles, 
there  are  probably  not  a  few  who  do  not  understand  the  peculiar  advan- 
tages of  them.  I  am  quite  sure  of  this  because  of  the  popularity  of  a  cer- 
tain holder  which  defeats  the  very  object  of  the  needle  which  it  is  designed 
to  hold. 

The  ordinarily  strongly  curved  needles — needles  curved  on  the  flat — 
must  be  grasped  by  the  needle-holder  in  such  a  way  that  one  jaw  of  the 
holder  presses  the  concave  side  of  the  needle  at  two  points  and  the  other 
jaw  presses  the  convex  side  of  the  needle  at  an  intermediate  point.  If  it 
be  necessary  to  exercise  much  pressure  the  needle  grasped  in  this  way  may 
readily  be  broken. 

Inasmuch  as  strongly  curved  needles  are  used  as  a  rule  only  for  the 
application  of  more  or  less  difficult  stitches — of  stitches  in  the  deeper  re- 
cesses of  wounds — the  breaking  of  such  a  needle  just  before  the  completion 
of  a  stitch  may  be  very  annoying. 

Hagedorn's  needles  are  curved  on  the  edge  and  flattened  on  the  sides. 
They  cannot,  except  with  great  force,  be  broken  by  a  holder  which  grasps 
them  properly — which  grasps  their  straight,  flat  sides. 

New  holders  for  Hagedorn's  needles  are  devised  almost  every  year.  One 
of  the  holders,  the  most  popular  one  perhaps  in  the  country,  was  devised 
about  six  years  ago  by  a  New  York  practitioner.  It  grasps  the  needles  by 
their  curved  edges  and  thus  exposes  the  needles  to  the  very  danger  which 
they  were  devised  to  prevent. 

Twenty  years  or  more  before  Dr.  Hagedorn  described  his  needles  it  had 
occurred  to  Dr.  Joseph  Schnotter,  attending  surgeon  to  the  German  Hos- 
pital, New  York,  to  devise  not  only  needles  precisely  like  the  so-called 
Hagedorn  needles  but  also  a  needle-holder  essentially  the  same  as  that  which 
Dr.  Hagedorn  regards  as  his  improved  needle-holder. 

A  few  years  ago  I  saw  Dr.  Schnotter's  original  needle-holder  among  the 
instruments  of  the  German  Hospital,  and  was  informed  that  it  had  seldom 
been  used  by  any  one  except  the  inventor. 

1  Brief  remarks  in  discussion  of  Dr.  J.  Whitridge  Williams'  demonstration,  "  A  new 
needle-holder."  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  February  2, 
1891. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1891,  ii,  63. 

5  49 


30L0F 


THE  INTRODUCTION  OF  "GUT-WOOL" 

AND  A  EEVIEW  OF  THE  BOOK 

"  ANLEITUNG  ZUE  ASEPTISCHEN  WUNDBEHANDLUNG  "  ' 

This  little  book  cannot  fail  to  do  good,  and  we  commend  it  to  every 
practitioner  and  student  of  surgery.  The  author  considers  his  subject  under 
the  following  heads : 

1.  The  significance  of  the  aseptic  treatment  of  wounds. 

2.  Air  and  contact  infection. 

3.  The  causes  of  wound  infection. 

4.  Disinfectants. 

5.  Disinfection  of  the  surface  of  the  body. 

6.  Sterilization  of  metal  instruments. 

7.  Aseptic  dressings. 

8.  Aseptic  sutures  and  ligatures. 

9.  Aseptic  wound  drainage. 

10.  Aseptic  materials  for  sponges. 

11.  Aseptic  injection  and  puncture. 

12.  Aseptic  employment  of  catheters  and  bougies. 

13.  Fluids  for  cleansing  and  irrigation. 

14.  Wards  and  operating  rooms. 

15.  Aseptic  operations  and  wound  treatment. 

16.  Aseptic  emergency  dressings  and  the  treatment  of  injuries. 

17.  Bibliography. 

One  would  not  expect  to  find  much  that  is  new  in  such  a  book  as  this; 
but  in  chapter  6  which  treats  of  the  sterilization  of  metal  instruments  the 
author  advocates  a  method  which  originated  with  him  and  which  he  de- 
scribed about  nine  months  ago  in  Langenbeck's  Archives.  The  instruments 
are  boiled  for  five  minutes  or  less  in  a  1  per  cent  solution  of  washing  soda. 
The  soda  prevents  the  rusting  of  the  instruments  and  increases  very  much 
the  sterilizing  power  of  hot  water. 

Behring  discovered  to  his  astonishment  that  the  ordinary  soda  lye  of  the 
laundry  at  a  temperature  of  85°  C.  killed  anthrax  spores  often  in  four 

1 A  review  of  the  book,  "  Anleitung  zur  aseptischen  Wundbehandlung  "  by  Dr.  C. 
Schimmelbusch,  and  remarks  on  the  introduction  of  "  gut-wool." 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1892,  iii,  63-64. 
50 


SURGICAL  TECHNIC  51 

minutes  and  always  in  eight  or  ten  minutes.  The  usual  concentration  of  the 
washing  lye  is  1.4  per  cent. 

In  the  author's  experiments  staphylococci  and  Bacillus  pyocyaneus  were 
killed  in  the  boiling  1  per  cent  soda  solution  in  two  to  three  seconds,  and 
anthrax  spores  which  in  several  instances  had  resisted  steam  at  100°  C. 
were  killed  in  two  minutes.  A  dipping  of  the  instruments  for  several  seconds 
would,  according  to  S.,  suffice  to  kill  the  pyogenic  organisms,  and  a  boiling 
for  five  minutes  in  the  soda  solution  should  satisfy  all  the  claims  of  ordinary 
practice. 

Sapidity  and  certainty  of  germ  destruction  are  not  the  only  advantages 
of  the  author's  method.  Of  great  worth  is  the  simplicity  of  its  accomplish- 
ment. One  requires  nothing  more  than  may  be  found  in  any  household — 
fire,  water,  washing  soda  and  a  vessel. 

The  author  has  devised  for  v.  Bergmann's  Klinik  an  apparatus  in  which 
to  boil  the  instruments.  It  provides  for  rapid  heating  of  the  water  and 
convenient  transfer  of  the  instruments.  Illustrations,  though  not  very  good, 
facilitate  the  description  of  the  apparatus.  The  instruments  having  been 
sterilized  are  transferred  to  trays  containing  carbol-soda  solution  (aa  1  per 
cent)  or  preferably  to  a  boiled  soda  solution  (1  per  cent). 

Accepting  Schimmelbusch  and  Behring's  experimental  results  we  have 
boiled  our  instruments  in  the  1  per  cent  soda  solution  ever  since  the  publi- 
cation of  Schimmelbusch's  article  about  nine  months  ago.  This  method 
has  a  disadvantage  which  Schimmelbusch  does  not  mention.  The  instru- 
ments are  so  slippery  when  removed  from  the  soda  solution  that,  for  us 
at  least,  it  is  practically  impossible  to  work  with  them.  We  have  been 
obliged,  therefore,  to  discard  the  use  of  the  carbol-soda  solution  (aa  1  per 
cent)  for  the  instrument  trays,  and  return  to  the  carbolic  acid  solution 
(1-30).  The  instruments  having  been  boiled  in  the  1  per  cent  soda  solu- 
tion are  thoroughly  rinsed  in  1-30  solution  of  carbolic  acid  before  being 
placed  in  the  instrument  trays. 

In  chapter  7,  page  104,  Schimmelbusch  informs  his  readers  that  catgut 
is  made  from  the  sheep's  intestine  and  not,  as  the  name  would  indicate, 
from  the  intestine  of  the  cat.  He  describes  the  manufacture  of  catgut  as 
follows : 

"  In  accordance  with  Lister's  directions,  the  small  intestine  of  the  sheep 
is  freed  of  its  mesentery,  washed  in  water,  and  then  manipulated  upon  a 
board  with  an  instrument  like  the  back  of  a  knife.  As  the  blunt  instrument 
is  drawn  with  a  scraping  motion  over  the  intestine  the  so-called  '  dirt '  is 
removed;  this  is  nothing  else  than  the  mucous  membrane  of  the  intestine. 
In  like  manner  the  circular  muscular  coat  is  rubbed  off,  so  that  only  the 
very  thin  tube  constituted  by  the  longitudinal  coat  remains,  which  may  be 
inflated  so  as  to  represent  a  well  preserved  delicate  tube-like  structure. 


52  SURGICAL  TECHNIC 

From  this  the  threads  are  manufactured  by  twisting,  and,  according  to  the 
thickness  desired,  either  the  entire  tube  or  strips  of  the  same  are  employed." 

To  suppose  catgut  to  be  made  from  the  longitudinal  muscular  coat  of  the 
intestine  might  be  an  excusable  error  if  a  knowledge  of  the  gross  anatomy 
of  the  wall  of  the  intestine  were  not  indispensable  to  every  surgeon.  To 
attempt,  for  instance,  a  circular  suture  of  the  intestine  without  any  knowl- 
edge whatever  of  the  coats  of  the  intestine  is,  to  say  the  least,  not  right.  No 
one  familiar  with  the  coats  of  the  intestine  would  for  a  moment  accept  the 
suggestion  that  catgut  is  made  from  the  longitudinal  muscular  coat,  or 
believe  that  this  coat  could  be  so  dissected  as  to  represent  a  perfect  tube 
which  might  be  distended  with  air.  Catgut  is  made  from  the  submucosa 
and  not  from  the  longitudinal  muscular  coat.  The  submucosa  *  is  the  most 
important  coat  of  the  intestine  for  the  surgeon.  "Without  it  a  circular  suture 
of  the  intestine  would  be  an  almost  certainly  fatal  operation.3  The  sub- 
mucosa may  be  readily  disengaged  from  the  other  coats  of  the  intestine  by 
simply  engaging  the  intestine  firmly  between  the  handles  of  a  scissors  and 
pulling  the  intestine.  The  handles  allow  nothing  but  the  submucous  coat 
to  pass  between  them.  The  serous  and  muscular  coats  become  stripped  off 
from  the  outer  side  and  the  mucous  coat  from  the  inner  side  of  the  intestine. 
The  submucosa  may  then  be  inflated  and  dried.  From  the  submucosa  ob- 
tained in  this  way  we  have  made  what  we  call  gut-wool*  We  use  this  gut- 
wool  solely  for  the  purpose  of  stopping  excessive  haemorrhage  from  bone. 
To  manufacture  the  gut-wool  the  dried  submucosa  is  moistened  with  abso- 
lute alcohol  and  cut  into  fine  shreds  with  a  tobacco-cutting  machine.  The 
wool  is  then  preserved  in  an  alcoholic  solution  of  corrosive  sublimate 
(1-1000).  To  plug  bone  sutures  or  bleeding  points  in  bone  take  a  very 
small  quantity  of  the  wool  in  a  sharp-pointed  forceps  and  press  it  into  the 
bone.  We  have  found  this  to  be  an  instantaneous  and  infallible  method  of 
arresting  haemorrhage  in  bone. 

Chapter  15,  on  aseptic  operating  and  the  aseptic  treatment  of  wounds, 
disappoints  us.  Schimmelbusch  entertains  v.  Bergmann's  great  dread  of 
blood  in  wounds,  and  upholds  the  assertion  made  ten  years  ago  by  the 
latter,  that  no  surgeon  should  look  for  good  results  who  does  not  with  the 

1  Halsted :  Circular  Suture  of  the  Intestine.  American  Journal  of  Medical  Sciences, 
October,  1887.  Halsted:  Intestinal  Anastomosis.  Johns  Hopkins  Hospital  Bulletin, 
No.  10,  January,  1891. 

•Rummer's  operation  (vid.  Archiv  fur  klin.  Chirurgie,  1891,  Bd.  xlii,  Heft  4),  is  a 
badly  conceived  one.  I  have  tested  it  four  times  on  dogs.  All  of  the  dogs  died  sooner 
or  later  from  perforation.  The  muscular  "  cuffs  "  unsupported  by  the  submucosa 
expand  into  the  thinnest  conceivable  film  and  finally  rupture. 

4  An  original  contribution  by  Dr.  Halsted. — Editor. 


SURGICAL  TECHNIC  53 

greatest  care  stop  every  bleeding  point.  Our  work  alone/  clinical  and  ex- 
perimental, has  taught  us  not  to  fear  a  dead  space  occupied,  without  ten- 
sion, by  a  blood  clot  more  than  an  obliterated  dead  space  whose  walls, 
constricted  by  obliteration  sutures,  are  studded  with  ligatures  and  little 
areas  of  strangulated  tissues.  The  rapidity  with  which  granulation  tissue 
fills  a  dead  space  is  marvelous,  provided  the  circulation  of  the  walls  of  the 
dead  space  be  vigorous  and  has  not  been  interfered  with  by  ligatures  or 
sutures.  A  cavity  as  large  as  an  English  walnut  in  the  cancellous  tissue  of 
bone,  for  example,  may  become  completely  filled  with  granulation  tissue  in 
forty-eight  hours.  Whether  antiseptic  precautions  be  employed  or  not,  the 
blood  clots,  occupying  freshly  made  dead  spaces,  become,  as  a  rule,  promptly 
"  organized,"  and  very  rarely  break  down,  even  when  they  have  been  inocu- 
lated with  pyogenic  microorganisms.0  In  only  one  instance  did  an  inocu- 
lated blood  clot  break  down. 

The  drainage  tube  is  of  necessity  a  part  of  the  technic  of  those  who 
insist  upon  perfectly  dry  wounds.  It  would  be  illogical  for  them  to  close 
absolutely  their  wounds,  for  the  dead  spaces  which  necessarily  exist  in 
almost  every  wound  must  become  filled  with  something,  either  blood  or 
transudate,  and  this  fluid  something  is  according  to  the  advocates  of  this 
method  a  thing  to  be  feared  and  gotten  rid  of.  The  dead  space  may  be 
exceedingly  small,  but  what  is  true  for  the  large  must,  in  a  measure,  be 
true  for  the  small  dead  spaces,  and  one  can  hardly  conceive  of  a  dead  space 
too  small  to  lodge  bacteria  and  to  contain  food  for  them.  But  one  cannot 
attempt  to  drain  minute  dead  spaces  nor,  perhaps,  any  but  large  ones.  How 
then  can  the  believers  in  the  absolutely  dry  method  explain  their  own  good 
results  ? 

The  objections  to  the  insertion  of  drainage  tubes  into  wounds  have  been 
well  summed  up  by  Welch,7  as  follows : 

First,  the}'  tend  to  remove  bacteria  which  may  get  into  a  wound  from 
the  bactericidal  influence  of  the  tissues  and  animal  juices.  Second,  bacteria 
may  travel  by  continuous  growth  or  in  other  ways  down  the  sides  of  a  drain- 
age tube  and  so  penetrate  into  a  wound  which  they  otherwise  would  not 
enter.  We  have  repeatedly  been  able  to  demonstrate  this  mode  of  entrance 
into  a  wound  of  the  white  staphylococcus  found  so  commonly  in  the  epi- 

5  Johns  Hopkins  Hospital  Reports,  Vol.  2,  No.  5,  Surgical  Fasc. 

6  Experiments  on  the  so-called  organization  of  the  blood  clot  by  Dr.  Welch,  Dr.  W. 
T.  Howard,  Jr.,  and  myself  in  the  Pathological  Laboratory  of  The  Johns  Hopkins  Uni- 
versity and  Hospital,  vid.  Welch:  Conditions  underlying  the  Infection  of  Wounds, 
Am.  Jour,  of  the  Medical  Sciences,  November,  1891. 

7  Some  considerations  concerning  antiseptic  surgery.  Md.  Med.  Jour.,  November 
14,  1891. 


54  SURGICAL  TECHNIC 

dermis.  The  danger  of  leaving  any  part  of  a  drainage  tube  exposed  to  the 
air  is  too  evident  to  require  mention.  Third,  the  changing  of  dressing 
necessitated  by  the  presence  of  drainage  tubes  increases  in  proportion  to 
its  frequency  the  chances  of  accidental  infection.  Fourth,  the  drainage  tube 
keeps  asunder  tissues  which  might  otherwise  immediately  unite.  Fifth,  its 
presence  as  a  foreign  body  is  an  irritant  and  increases  exudation.  Sixth, 
the  withdrawal  of  tubes  left  any  considerable  time  in  wounds  breaks  up 
forming  granulations  and  thus  both  prolongs  the  process  of  repair  and 
opens  the  way  for  infection.  Granulation  tissue  is  an  obstacle  to  the  inva- 
sion of  pathogenic  bacteria  from  the  surface,  as  has  been  proven  by  experi- 
ment. Seventh,  after  removal  of  the  tube  there  is  left  a  tract  prone  to  sup- 
purate and  often  slow  in  healing. 

The  first  and  second  objections  are,  I  believe,  original  with  Dr.  Welch. 
I  would  add  an  eighth  objection.  Tissues  which  have  been  exposed  to  the 
drainage  tube  are  suffering  from  an  insult  which  impairs  more  or  less  their 
vitality  and  hence  their  ability  to  destroy  or  inhibit  microorganisms. 


THE  OPERATIVE  REDUCTION  OF  AN  OLD  DISLOCATION  OF 
THE  ELBOW1 

This  case  is  the  most  interesting  one  that  we  have  had  for  some  time. 
This  little  boy  dislocated  his  elbow  about  four  months  ago.  It  was  a  dis- 
location of  both  bones  of  the  forearm  backwards.  He  could  not  flex  his  arm 
at  all.  Pronation  and  supination  were  very  limited  in  extent.  The  bones 
were  in  the  usual  position,  the  forearm  bent  at  an  angle  of  45  degrees  with 
the  straight  line  of  the  arm.  Up  to  this  time  no  one  has  succeeded  in  reduc- 
ing an  old  dislocation  of  the  elbow-joint  without  exsection  of  bones  and 
usually  a  typical  exsection.  Recently  F.  Bassel-Hagen,  of  Heidelberg,  has 
published  all  the  cases  he  could  collect,  eleven  in  number,  and  in  all  of  them 
there  was  more  or  less  typical  exsection  of  the  bones  made.  This  is  the 
fourth  case  that  I  have  operated  upon.  Heretofore  I  have  always  exsected 
the  bones.  It  occurred  to  me  that  after  all  we  could  probably  reduce  these 
old  dislocations  if  we  could  only  overcome  the  shortening  of  the  triceps 
muscle  which  ensues  after  the  dislocation.  The  idea  suggested  itself  to  me 
from  several  cases  of  fracture  of  the  patella  which  we  have  had,  where  we 
have  brought  down  the  patella  sometimes  three  or  four  inches.  In  this  case 
we  cut  through  the  olecranon  where  the  two  processes  join.  "We  then 
removed  the  new  tissue  which  had  filled  up  the  space  formerly  occupied  by 
the  articular  surface  of  the  ulna,  that  is,  the  lower  articular  surface  of  the 
humerus,  which  was  covered  with  new  connective  tissue.  We  excised  that, 
and  then  dissected  the  triceps  tendon  well  up  on  the  arm,  and  by  transverse 
cuts  on  its  under  surface  we  were  able  to  draw  it  down  as  far  as  necessary 
in  order  to  make  it  meet  the  ulna  which  had  already  been  replaced.  This 
is  the  first  case  of  the  kind  on  record.  We  have  one  to  do  tomorrow  which  I 
hope  will  result  successfully.  It  is  now  nearly  four  weeks  since  this  has 
been  done.  Although  it  pains  the  boy  to  move  it,  you  see  he  can  rotate  it 
considerably,  and  there  is  already  quite  a  little  flexion.  We  shall  certainly 
be  able  to  flex  it  more  than  a  right  angle,  and  if  we  can  extend  it,  as  I  am 
sure  we  can  in  time,  that  will  be  an  excellent  result. 

1  Presented  before  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  April 
3, 1893. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1893,  iv,  97. 


55 


TWO  CASES  OF  EXCISION  OF  THE  KNEE-JOINT  IX  WHICH 

HANSMANN'S  PLATES  WITH  ORDINARY  SCREWS 

WERE  EMPLOYED1 

Case  1. — Woman,  47  years  old.  Two  months  ago  she  had  a  miscarriage 
which  was  followed  by  pyaemia.  Both  knee-joints  became  infected.  The 
right  one  recovered  prior  to  her  admission  to  the  hospital.  On  admission, 
six  weeks  ago,  the  left  knee-joint  was  distended  with  a  puro-synovial  fluid. 
This  fluid  was  withdrawn  soon  after  admission  through  an  aspirating  needle, 
and  the  joint  subjected  to  a  prolonged  washing  with  a  solution  of  hydrarg. 
bichlor.  (1-1000).  The  pain,  which  had  been  great,  subsided  after  the 
aspiration  and  washing,  and  the  temperature,  which  had  been  99°  to  101°, 
became  lower  for  about  one  week.  Then  the  symptoms  of  pus  in  the  joint 
reappeared  and  the  aspiration  and  washing  were  repeated  in  two  weeks, 
this  time  with  perhaps  less  success  than  at  first.  The  patient  absolutely 
refused  further  operative  treatment  for  three  weeks.  In  the  meantime  the 
inflammation  of  the  joint  made  rapid  strides.  The  joint  was  distended  to 
its  utmost  capacity  with  pus.  The  tissues  about  the  joint  were  infiltrated 
and  the  skin  was  red  and  tense.  Ultimately,  and  when  the  patient's  general 
condition  had  become  so  bad  that  her  life  was  almost  despaired  of,  she  con- 
sented to  an  operation. 

A  transverse  incision  was  made  through  the  skin  and  patella,  then  two 
longitudinal  incisions,  making  with  the  first  the  letter  H.  The  internal 
longitudinal  incision  opened  a  dissecting  extracapsular  abscess.  The  joint 
was,  as  I  have  said,  filled  with  pus.  The  cartilages  were  still  intact.  The 
crural  ligaments  were  softened,  but  had  not  yet  parted.  A  horizontal  slice 
about  1.5  cm.  was  taken  from  the  tibia,  and  a  somewhat  thicker  slice  from 
the  femur.  Such  portions  of  the  femur  cartilages  as  were  not  removed  with 
this  slice  were  shaved  off  subsequently.  I  make  it  a  principle  never  to  leave 
exposed  cartilage  in  a  wound.  The  walls  of  a  dead  space  should  never  be  of 
tissues  which  cannot  furnish  granulations  readily.  The  bones  were  held 
together  by  Hansmann's  plates  and  my  screws. 

The  knee  is  already  perfectly  firm,2  although  it  is  only  three  weeks  since 
the  operation.  The  wound  has  healed  absolutely  per  primam,  notwith- 
standing the  fact  that  the  operation  was  performed  through  actively  sup- 
purating tissues,  and  notwithstanding  possibly  the  still  more  important  fact 
that  the  patient's  vitality  was  at  a  critically  low  ebb  at  the  time  of  the 

1  Probably  the  first  report  of  cases  treated  by  buried  screws  and  Hansmann's  plates. 
(W.  S.  H.)  Presented  before  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore, 
December  18, 1893. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1894.  v.  31. 

1  January  18,  1894.    The  knee  became  absolutely  firm  within  five  weeks  of  the 
operation.  The  patient  is  perfectly  well  and  entirely  free  of  pain. 
56 


EXCISION  OF  THE  KNEE-JOINT  57 

operation.  I  have  repeatedly  called  your  attention  to  the  objections  to 
Hansmann's  screws  which,  beyond  the  flange,  have  a  shank  long  enough 
to  project  through  the  skin  wound.  They  must  be  ultimately  removed,  and 
they  necessarily  lead  to  suppuration.  My  screws  are  so  short  that  when 
screwed  home  they  are  almost  flush  with  the  plate.  They  are  designed  to 
remain  in  the  wound.  It  has  occurred  to  me  that  possibly  staples  over  stiff 
wire  might  well  replace  the  plate  and  screw  method.  The  staples  could  be 
very  fine  and  might  be  clinched  on  the  other  side  of  the  bone  if  necessary. 

Case  2. — Woman,  24  years  old.  This  patient  had  a  tuberculous  knee- 
joint  which  was  treated  for  many  months  with  iodoform-glycerine  injec- 
tions, without  much  success.  Excision  was  finally  decided  upon  and  per- 
formed four  weeks  ago.  A  modified  Helferich's  method  of  excising  was 
employed.  The  bones  are  cut  in  such  a  way  that  the  convex  lower  end  of 
the  femur  fits  more  or  less  accurately  into  the  concave  upper  end  of  the 
tibia.  We  usually  make  use  of  this  method,  or  a  modification  of  it,  in 
excising  tuberculous  knee-joints.  The  semicircular  cut  into  the  head  of  the 
tibia  sometimes  reveals  and  partially  or  wholly  removes  tuberculous  foci 
which  might  be  overlooked  if  the  bones  were  simply  trimmed  in  the  usual 
way.  By  this  method,  or  rather  a  modification  of  it,  the  cartilage  of  the 
femur  is  thoroughly  removed  and  the  condyles  so  trimmed  that  any  tubercu- 
lous invasion  of  them  is  almost  sure  to  be  exposed.  In  short,  we  make  a 
virtue  of  necessity,  for  in  trimming  the  bones  to  the  desired  shape  we  may 
eradicate  the  disease. 

When  the  knee-joint  has  been  excised  in  this  way,  and  it  has  not  been 
necessary  to  remove  too  much  bone,  the  femur  locks  into  the  tibia  so  firmly 
when  the  leg  is  extended  that  there  is  little  tendency  to  displacement. 
When  the  plates  and  screws  are  used  the  bones  are  held  still  more  firmly 
in  position. 

Helferich's  method  of  excising  the  knee-joint  was  devised  for  joints  which 
are  ankylosed  in  a  flexed  position.  He  believes  that  with  the  semicircular 
incision  he  gets  less  shortening  of  the  limb  than  when  he  cuts  out  the  usual 
wedge-shaped  piece  of  bone.  We  are  very  much  pleased  with  the  screw  and 
plate  method.  The  results  have  been  surprisingly  gratifying.  In  the  four 
or  five  previous  cases  in  which  we  have  used  them  the  ankylosis  has  been 
absolute.  In  no  case  has  there  been  suppuration,  and  in  no  case  have  the 
plates  and  screws  caused  the  patient  uneasiness. 


CONCERNING  INFLAMMATION  AND  SUPPURATION l 

I  am  not  prepared  at  present  to  entertain  the  notion  that  it  might  be 
practicable  to  reserve  the  term  inflammation  for  lesions  or  symptoms  caused 
by  microorganisms,  unless  it  was  impossible  to  simulate  what  we  should 
decide  to  call  inflammation  by  any  means  except  infection.  For  it  is  not 
always  possible  to  say  positively,  from  naked-eye  observation,  whether  in- 
flammation exists  or  not.  Shall  we  withhold  tentatively  the  term  inflam- 
mation until  the  results  of  the  bacteriological  examination,  however  pro- 
longed, are  made  known?  And  shall  we  accept  a  negative  result  as  proof 
that  microorganisms  have  not  been  or  are  not  present  ?  On  the  other  hand, 
we  may  have  an  infection  without  the  slightest  outward  manifestation  of  it. 

For  example,  a  recent  case  of  my  own.  A  cyst  of  the  tongue,  caused  by 
Staphylococcus  aureus,  without  a  sign  of  inflammation.  The  cyst  formed 
slowly,  without  pain  and  without  infiltration  or  redness  of  the  surrounding 
tissues.  It  was  perfectly  circumscribed,  as  large  as  a  hickory-nut,  and  con- 
tained a  perfectly  clear,  slightly  viscid  fluid.  Pure  cultures  of  Staphylococ- 
cus aureus  were  obtained. 

The  gonococcus  is  another  microorganism  which  at  times  is  a  malignant 
pyogenic  organism,  although,  as  a  rule,  it  does  not  produce  in  the  tissues 
disturbance  enough  to  be  recognized  as  inflammation.  "We  have  found  it 
quite  recently  in  pure  culture  in  pyarthrosis  of  the  knee.  Dr.  Welch  has 
recently  found  it  to  be  the  only  organism  in  a  case  of  multiple  abscesses  of 
the  viscera  and  virulent  ulcerative  endocarditis.  One  or  two  similar  cases 
of  endocarditis  caused  by  the  gonococcus  have  already  been  reported. 

Dr.  Park  believes  that  the  so-called  pyogenic  membrane  is  a  protection  to 
the  tissues  against  the  invasion  of  pus,  and  proposes  that  it  be  called  a 
pyophylactic  membrane.  Pyogenic  he  considers  a  misnomer.  I  agree  with 
him  that  it  might  be  well  to  drop  the  adjective  pyogenic,  but  I  should  hesi- 
tate to  recommend  pyophylactic  in  its  place.  I  did  not  suppose  that  the 
so-called  pyogenic  membrane,  its  name  notwithstanding,  was  still  believed 
to  have  a  particular  function.  We  regard  this  membrane  merely  as  the 
expression  or  result  of  Nature's  effort  to  repair  a  lesion,  subcutaneous  or 

1  Remarks  in  discussion  of  Dr.  Roswell  Park's  paper,  "  On  the  consequences  of 
hyperaemia  and  the  pathology  of  inflammation  and  suppuration."  American  Surgical 
Association,  New  York,  May  28-30,  1895. 

Tr.  Am.  Surg.  Ass,  Phila,  1895,  xiii,  249-251. 
58 


INFLAMMATION  AND  SUPPURATION  59 

otherwise.  The  thick  pleura,  the  masses  of  new  connective  tissue  in  tuber- 
culous knee-joints,  the  thick  hydrocele  sac  should  not  be  called  pyophylactic. 
The  object  of  the  thick  hydrocele  sac  is  not  to  protect  the  tissues  against 
the  invasion  of  pus. 

Whatever  the  stimulus  to  the  production  of  granulation  tissue,  these 
thick  membranes  are  its  products.  They  may  be  regarded  as  organized 
exudates  in  the  sense  of  an  organized  blood  clot  or  organized  thrombus. 
Konig  has  shown  that  the  fibrous  tissue  in  tuberculous  joints  is  produced 
by  the  organization  of  the  fibrinous  exudate. 

Archepyon  is  hardly  a  suitable  term  for  the  contents  of  the  usual  old 
"  cold  abscess."  The  contents  of  these  tuberculous  abscesses  is  not,  and  never 
was,  pus. 

Dr.  Park  has  omitted  one  microorganism  which  is  of  great  surgical  im- 
portance. It  is  Bacillus  aerogenes  capsulatus  (Welch).  Welch  and  Nuttall 
described  this  anaerobic  bacillus,  in  1892,  as  the  cause  of  rapid  formation 
of  gas  in  the  bloodvessels  and  tissues  after  death.  It  is  a  capsulated  thick 
bacillus,  from  3  to  6/x,  long.  Does  not  form  spores.  It  produces  gas  more 
rapidly  after  than  before  death.  If  the  inoculated  animal  is  killed  soon 
after  the  injection,  the  bacillus  develops  rapidly  and  with  the  production 
of  a  large  amount  of  gas  throughout  the  body.  The  gas  formation  in  the 
liver  has  riveted  the  attention  of  one  German  observer,  who  calls  the  infec- 
tion Shaumleber  (foam-liver).  Fraenkel's  Gasphlegmonen  were  undoubt- 
edly caused  by  this  bacillus.  Bacillus  phlegmones  emphysematosae  he 
calls  it. 

We  have  had  considerable  experience  with  this  bacillus  at  The  Johns 
Hopkins  Hospital,  thanks  to  Dr.  Welch's  prompt  recognition  of  it.  A  few 
weeks  ago  we  found  it  in  the  living  subject,  in  a  bullet  wound  of  the  knee- 
joint,  infected  twenty-four  hours  before  admission  to  the  hospital. 

Dr.  Bloodgood,  the  house  surgeon,  promptly  and  cleverly  recognized 
"  air  "  in  the  joint.  We  operated  at  once  and  found  gas  in  the  joint,  and, 
to  a  slight  extent,  in  the  surrounding  tissues.  The  bullet  was  found  in 
the  head  of  the  tibia,  about  3  cm.  from  its  joint  surface.  Bacillus  aerogenes 
capsulatus,  Staphylococcus  pyogenes  aureus,  and  a  streptococcus  were  cul- 
tivated from  the  joint  contents.  All  these  were  present  in  great  abundance. 
The  joint  was  opened  freely  on  both  sides.  An  Esmarch  rubber  bandage 
was  applied  about  12  cm.  above  the  joint  so  as  to  enable  us  to  irrigate  the 
joint  without  fear  of  absorption.  The  joint  was  irrigated  and  deluged  with 
many  gallons  of  a  solution  of  corrosive  sublimate,  1  to  1000.  The  patient, 
a  boy  about  twelve  years  old,  was  very  comfortable  for  two  days.  He  then 
developed  a  temperature  of  about  39.5°  C.  and  became  restless,  but  did 
not  complain  of  pain.    The  wound  was  promptly  dressed  and  looked  so 


60  INFLAMMATION  AND  SUPPUKATION 

perfectly  well  that  it  was  not  opened.  The  next  day,  the  temperature  con- 
tinuing and  increasing  a  little,  the  wound  was  torn  open  and  a  most  unusual 
picture  was  presented,  but  one  which  I  think  that  I  have  seen  more  than 
once  years  ago. 

To  one  who  had  seen  Dr.  Welch's  pigeons  and  rabbits  and  FraenkePs 
drawings  the  lesions  were  unmistakable.  The  muscles  about  the  joint 
seemed  in  places  to  have  melted  into  a  thick  puree-like  paste,  with  peculiar 
purple-brown  and  Burgundy-slate  colors.  There  was  no  distinct  evidence  of 
gas  formation.  There  was  no  pus.  The  aponeuroses  and  the  connective 
tissue  between  muscles  were  tinged  a  yellow-green.  I  feared  from  the  very 
rapid  and  extensive  lesions  that  even  a  high  amputation  would  not  save 
the  boy's  life.  I  had  read  of  the  almost  uniformly  fatal  cases  of  Schede, 
Sick,  and  others,  collected  by  Fraenkel,  and  knew  that  an  attempt  to  save 
the  limb  meant  almost  certain  death;  so  I  amputated  a  little  above  the 
middle  of  the  thigh,  left  the  wound  wide  open,  and  put  the  patient  into  the 
hot-water  bath.  He  was  kept  in  this  bath  until  he  was  thoroughly 
convalescent. 


BICHLORIDE  IRRIGATIONS  * 

In  these  cases  of  knee-joint  irrigation  we  do  not  hope  to  do  more  than 
to  greatly  inhibit  the  activity  of  the  microorganisms — to  assist  the  tissues 
to  destroy  the  microorganisms.  It  is  rarely  necessary  to  do  more  than  incise 
an  acute  abscess ;  the  tissues  do  the  rest.  And  yet  we  know  that  the  tissues 
about  the  abscess  have  been  invaded  by  the  pyogenic  microorganisms.  In 
irrigation  of  the  knee-joint  we  do  not  expect  to  reach  the  microorganisms 
outside  of  the  joint. 

In  the  last  case  reported  by  Dr.  Finney — the  one  with  triple  infection — 
I  do  not  feel  at  all  sure  that  we  could  not  have  taken  care  of  the  joint 
itself.  We  amputated  because  in  a  few  days  we  found  the  tissues  in  the 
thigh  almost  up  to  the  hip-joint  invaded  by  the  organisms  to  a  shocking 
extent,  with  lesions  characteristic  of  the  air-producing  bacillus. 

That  solutions  of  bichloride  of  mercury  are  more  efficacious  than  salt 
solutions  in  destroying  and  inhibiting  pyogenic  organisms  outside  of  the 
body  we  have  sufficient  proof.  There  is  also  abundant  clinical,  if  not  wholly 
conclusive  experimental  evidence  that  the  same  is  true  in  the  tissue  spaces, 
in  joints,  etc. 

The  irrigation  of  the  urethra  in  the  treatment  of  gonorrhoea  furnishes 
a  good  clinical  example  of  the  benefits  to  be  derived  from  solutions  of 
corros.  sub.  Here,  too,  the  specific  microorganisms  have  been  demonstrated 
in  the  tissues  outside  of  the  urethra. 

2 1  speak  from  a  great  deal  of  experience — from  daily  observations  for 
five  years  (1880-85)  in  the  Roosevelt  Hospital  Dispensary,  New  York.  In 
this  work  I  was  very  ably  assisted  by  Drs.  Richard  Hall  and  Frank  Hartley 
of  New  York.  The  salt  solutions  are  worse  than  ineffectual  in  the  treat- 
ment of  gonorrhoea.  With  them  we  never  succeeded  in  aborting  a  case  of 
gonorrhoea,  either  in  private  or  dispensary  practice,  but  we  constantly 
induced  a  cystitis  and  epididymitis.  With  the  bichloride  irrigation,  not  a 
single  case  of  cystitis  or  epididymitis  occurred  in  these  five  years.  I  think 
that  we  have  had  the  same  experience  in  the  dispensary  here.  Dr.  James 
Brown  told  me  less  than  a  year  ago  that  he  had  never  produced  cystitis  or 

1  Remarks  in  discussion  of  Dr.  John  M.  T.  Finney's  paper,  "  Pyarthrosis."  The  Johns 
Hopkins  Hospital  Medical  Society,  Baltimore,  October  7,  1895. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1895,  vi,  164. 

2  This  paragraph  refers  to  an  original  contribution  of  Dr.  Halsted  in  the  treatment  of 
gonorrhoea  by  dilute  bichloride  solutions. — Editor. 

61 


62  ANTISEPTIC  SURGERY 

epididymitis  with  bichloride  irrigation.  In  private  practice  it  is  very  com- 
mon, indeed  it  is  the  rule,  to  abort  a  gonorrhoea  within  a  week  or  ten  days 
with  bichloride  irrigation.  Previous  to  the  use  of  this  irrigation  I  used 
to  dread  to  have  a  gonorrhoea  case  come  to  my  office ;  after  its  introduction 
I  was  glad  to  see  them.  The  treatment  became  so  popular  that  certain 
specialists  in  New  York  said  that  they  would  never  use  it  because  it  was 
ruining  their  practice.  Men  after  a  few  visits  were  cured.  Nor  would  they 
return  when  a  fresh  urethritis  was  contracted.  Furthermore,  they  taught 
their  friends  how  to  treat  themselves.  It  would  be  too  much  of  a  digression 
to  give  the  details  of  this  treatment  at  this  time.  But  I  must  ask  your 
permission  to  say  that  everything  depends  upon  the  intelligent  use  of  the 
method.  The  required  strength  of  the  solution  is  determined  by  the  use  of 
the  microscope  and  by  the  tolerance  of  the  particular  urethra.  The  strength 
to  be  used  varies  from  1 :  200,000  to  1 :  25,000.  A  tolerance  of  the  stronger 
solutions  has,  usually,  to  be  acquired.  Men  with  red  hair  have,  as  a  rule, 
sensitive  urethrae. 

3  The  gonococci  disappear  promptly  from  the  urethral  discharge  after 
irrigation  with  solutions  of  corrosive  sublimate,  but  are  uninfluenced,  ap- 
parently, by  irrigation  with  the  salt  solution. 

s  Reference  to  counting  the  bacteria  as  a  method  of  estimating  the  value  of  the 
antiseptic  solution. — The  Editor. 


CONCERNING  DRAINAGE  AND  DRAINAGE  TUBES1 

I  cannot  endorse  Dr.  Moore's  views  as  to  drainage  of  the  knee-joint  after 
suture  of  the  fractured  patella.  We  rarely  put  drains  of  any  kind  into  the 
knee-joint,  even  though  it  be  infected.  A  drain  can  relieve  tension,  but 
it  cannot  dispose  of  all  of  the  organisms  of  an  infected  joint;  the  tissues 
have  to  take  care  of  these  in  a  large  measure,  and  they  can  often  do  this 
better  without  a  drain  than  with  it.  A  drain  produces  invariably  some 
necrosis  of  the  tissues  with  which  it  comes  in  contact,  and  enfeebles  the 
power  of  resistance  of  these  tissues  toward  organisms.  But  given  necrotic 
tissues  plus  infection,  a  drain  becomes  almost  indispensable.  In  abdominal 
cases,  for  example  (I  am  now  speaking  of  the  principles  of  drainage  in 
general),  it  is  not  sufficient  to  drop  a  drainage  tube  or  a  piece  of  gauze 
down  into  the  middle  of  a  necrotic  area;  the  entire  necrotic  area  should 
be  circumscribed  by  gauze  packing  and  excluded  in  this  way  from  the  rest 
of  the  peritonaeal  cavity.  No  drainage  at  all  is  better  than  the  ignorant 
employment  of  it. 

1  Remarks  in  discussion  of  Dr.  Charles  A.  Power's  paper,  "  The  question  of  operative 
interference  in  recent  simple  fractures  of  the  patella."  American  Surgical  Association, 
New  Orleans,  La.,  April  19-21,  1898. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1898,  xvi,  103. 


63 


CAEEEL-DAKIN  METHOD  OF  THE  TEEATMENT  OF  INFECTED 
WOUNDS.    ANTISEPTICS   IN  THE  ASEPTIC  PEEIOD l 

We  were  most  fortunate  in  having  with  us  last  winter  Dr.  Joseph  S. 
Lawrence,  who  for  several  months  had  been  in  charge  of  the  bacterial  work 
of  the  American  Ambulance  at  Neuilly  and  had  thoroughly  familiarized 
himself  with  the  details  of  the  new  antiseptic  work.  Dr.  Lawrence  made  all 
of  our  bacterial  counts  and  carefully  supervised  the  technical  details  of  the 
wound-treatment.  We  were  able  to  confirm  unqualifiedly  the  claims  made 
for  the  method  by  Carrel  and  Dehelly,  Depage,  Tuffier,  Debaisieux,  Lagasse, 
and  some  others. 

At  the  outset  of  our  work  with  the  Dakin-Daufresne  solution  we  repeated 
on  the  human  subject  the  experiments  made  by  Carrel  on  dogs  at  the  Eocke- 
feller  Institute.2  Our  patients  readily  consented  to  the  experiments,  which 
consisted  merely  in  the  removal  of  two  squares  of  skin  at  symmetric  points 
on  the  abdomen  and  observing  the  process  and  rate  of  healing  under  various 
contrasted  conditions.  The  square  defect  on  one  side  of  the  abdomen 
would  be  treated  with  the  Dakin  solution,  and  on  the  other  either  without 
an  antiseptic  or  with  naphthalin,  blue  ointment,  nitrate  of  silver,  et  al. 
The  healing  under  the  Dakin  solution  was  marvelously  rapid,  and  the 
results  so  uniform  that  we  accepted  it  as  a  standard  for  comparison  with 
other  methods,  such  as  dry  scab,  moist  blood-clot,  dry  cell,  grafts  deprived 
of  epithelium  and  applied  inside  out,  etc.  Although  not  quite  prepared  to 
report  our  results,  we  can  confidently  affirm  that  the  granulating  wounds 
treated  with  the  Dakin  solution  healed  much  more  rapidly  than  any  treated 
by  other  antiseptics. 

Are  you  not  surprised  to  note  the  absence  of  any  reference  to  dead  spaces 
in  the  writings  either  of  those  who  extol  or  those  who  condemn  the  Carrel 
method?  We  know,  of  course,  as  Moynihan  has  emphasized  in  a  recent 
paper,  that  fresh  wounds  of  soft  parts  may,  after  scrupulous  toilet,  and 
without  the  employment  of  antiseptics,  be  closed  with  a  fair  prospect  of 
healing  by  first  intention ;  and  we  have  frequently  observed  that  even  after 
amputation  through  infected  tissues  the  undrained  wound  may  heal  per 
primam,  provided  that  no  dead  space  is  left.    If  a  dead  space  cannot  be 

1  Letter  to  Dr.  William  W.  Keen,  December  14,  1917. 

In:  "  The  treatment  of  war  wounds  "  (W.  W.  Keen),  Phila.,  1918,  2d  ed.,  252-259. 

2  Jour.  Amer.  Med.  Assoc,  December  17,  1910. 

64 


ANTISEPTIC  SURGERY  65 

avoided  without  prejudicing  the  vitality  of  the  tissues  used  to  occlude  it, 
the  apposed  soft  parts  may  still  unite  primarily  if  the  dead  space  at  the  end 
of  the  sawed-off  bone  is  drained. 

Having  convinced  myself  of  the  remarkable  effect  of  the  Dakin-Daufresne 
solution  upon  infected  wounds,  I  cherished  the  hope  that  possibly  involu- 
cral  cavities,  if  sterilized  to  the  required  degree,  might,  after  closure,  fill 
with  granulations  before  the  inhibited  organisms  would  recover  sufficiently 
to  defeat  the  healing  process.  As  every  surgeon  knows  to  his  mortification, 
cases  of  osteomyelitis  in  which  the  sequestrum  has  or  has  not  been  removed 
may  go  from  clinic  to  clinic  for  twenty  years  or  more  in  the  hope  of  having 
their  fistulous  tracts  healed.  It  would,  therefore,  be  a  great  boon  to  both 
patient  and  surgeon  if  by  the  Carrel  method  the  old  involucral  cavities  could 
be  healed. 

In  four  cases  last  year  Dr.  Dandy,  our  resident  surgeon,  irrigated  for 
from  twenty-five  to  thirty  days  with  the  Dakin  solution,  according  to  the 
Carrel  method,  the  properly  prepared  involucral  cavities,  and  then,  the 
microorganisms  having  been  reduced  for  six  or  more  days  to  about  1  in  10 
fields  (the  counts  were  made  by  Dr.  Lawrence),  the  soft  parts  were  trimmed 
and  the  wounds  closed.  For  about  six  weeks  in  one  case,  eight  weeks  in  two 
cases,  and  three  weeks  in  a  fourth  the  wounds  remained  closed  and  without 
evidence  of  revivement  of  the  bacteria.  Then  the  tissues  became  slightly 
inflamed  and  the  wounds  opened. 

In  a  fifth  case  a  fracture  of  the  operatively  reduced  involucrum  occurred 
and  the  fragments  were  wired  together.  In  this  instance  the  Carrel  irriga- 
tion was  continued  for  about  two  months — until  the  bony  cavity  had  filled 
and  the  wound  healed.  Now,  six  months  later,  the  wound  is  still  firm  and 
the  fracture  united.3  So,  too,  in  circumscribed  bone  abscesses,  thanks  to  the 
care  and  interest  of  Dr.  Dandy  and  Dr.  Lawrence,  we  have  had  admirable 
results  with  the  method  when  the  irrigation  was  continued  until  the  cavity 
became  filled  with  the  new  tissue. 

Evidently,  in  the  unsuccessful  cases,  the  bony  cavities  with  eburnated 
involucral  walls  produced  granulations  so  slowly  that  the  inhibited  organ- 
isms recovered  before  the  dead  spaces  became  filled  with  living  tissue.  Thus 
the  Carrel  method  will  fail  if  the  dead  space  is  too  large  or  its  walls  are  too 
feeble  to  furnish  sufficient  granulation  tissue  in  the  required  time.  Dead 
spaces,  and  not  alone  devitalized  bone  or  soft  parts,  must  surely  be  a  con- 
tributing cause  of  the  failure  of  the  Carrel  method  in  many  cases  of  com- 
pound fracture.    Even  in  amputations  the  dead  space  between  the  end  of 

*  Fancy  what  the  result  would  have  been  in  this  case  had  the  wound  not  been 
sterilized. 


66  ANTISEPTIC  SURGERY 

the  bone  and  the  muscles  might  be  responsible  for  the  defeat  of  the  sur- 
geon's best  efforts.  Granulation  tissue  must  fill  the  empty  space  before 
the  bacteria  in  its  fluid  contents  revive,  otherwise  the  wound  will  break 
down.  The  walls  of  an  infected  dead  space,  enlarged  from  exudate  or  per- 
haps from  a  haemorrhage,  become  tense  and  relatively  devitalized,  and 
thus  the  infection  may  spread  to  parts  of  the  wound  which  have  healed,  and 
beyond.  One  should  not  demand  the  impossible  from  the  Carrel-Dakin 
treatment. 

In  civil  practice  we  should,  I  think,  sterilize  every  granulating  wound, 
whether  abscess,  sinus,  or  superficial  ulcer ;  and  attempt  the  sterilization  of 
fistulae.  Surgeons  will  ultimately  appreciate  the  magnitude  of  the  lessons 
taught  by  Carrel,  chief  of  which  is  that  wounds  may  be  practically  sterilized 
by  the  constant  contact  of  mild  antiseptics.  The  contributions  of  Dakin 
are  of  almost  equal  importance,  and  indicate  that  it  is  chiefly  the  chemist 
to  whom  we  must  now  look  for  further  developments  in  the  treatment  of 
wounds  in  general. 

Antiseptics  in  the  Aseptic  Period* — In  the  Surgical  Clinic  of  The  Johns 
Hopkins  University  we  have  never  abandoned  the  use  of  chemical  anti- 
septics. The  surgeon  who  has  lived  in  the  days  before  Listerism  needs  no 
modern  proof  of  their  value.  So  far  back  as  1884  we  had  irrefutable  con- 
firmation of  Carrel's  view  of  the  inhibitive  action  of  mild  antiseptic  solu- 
tions. Gonorrhoea  was  promptly  cured  by  frequent  irrigations  of  very  large 
quantities  (3000  c.  c.)  of  solutions  of  the  bichloride  of  mercury  as  weak 
as  1 :  50,000,  or  even  1 :  100,000.  The  strength  of  the  solution  could  be 
gradually  increased  to  1 :  20,000.  From  day  to  day  we  noticed  the  rapid 
diminution  in  the  number  of  the  Xeisser  cocci. 

Since  the  first  years  of  The  Johns  Hopkins  Hospital  the  treatment  of 
our  infected  joints  has  been  as  follows:  An  Esmarch  bandage  is  applied 
above  the  affected  joint  to  prevent  absorption  of  the  antiseptic ;  the  joint  is 
opened  freely,  flushed  with  the  antiseptic  solution  for  five  or  ten  or  even 
fifteen  minutes,  and  then  closed.  If  necessary,  the  procedure  is  repeated  in 
a  few  days,  and  then  perhaps  again.  The  results  in  these  cases  alone  should 
convince  one  of  the  value  of  antiseptics. 

Further  proof  (if,  indeed,  fresh  proof  were  needed)  of  their  action  we 
have  from  year  to  year  in  the  results  of  the  blood-clot  treatment  of  old 
involucral  cavities.  These  cavities  are  cleaned  with  meticulous  care.  Every- 
where, both  in  bone  and  soft  parts,  only  freshly  cut  surfaces  remain  as  walls 

*  A  further  reference  to  Dr.  Halsted's  original  contribution  to  the  treatment  of 
gonorrhoea  with  dilute  bichloride  solutions.  Also  a  reference  to  Dr.  Halsted's  contri- 
bution to  the  counting  of  bacteria  as  a  method  of  estimating  the  effectiveness  of  the 
antiseptic  solution. — The  Editor. 


ANTISEPTIC  SUKGEKY  67 

of  the  dead  space.  Pure  carbolic  acid  is  poured  freely  into  the  cavity 
(formalin  may  be  as  good  or  better)  and  scrubbed  over  all  the  raw  surfaces 
for  several  minutes.  Then  for  a  prolonged  period  the  wound  is  flushed  with 
gallons  of  a  corrosive  sublimate  solution — 1 :  1000.  The  wound  is  loosely 
closed  with  a  buried  continuous  wire  suture,  the  Esmarch  bandage  removed, 
and  the  cavity  allowed  to  fill  with  blood.  Many  layers  of  silver-foil  are  laid 
over  the  line  of  the  suture,  and  over  this  the  paper.  The  wound  should  not 
be  investigated  for  two  or  three  weeks  unless  there  is  reason  to  believe  that 
the  clot  has  broken  down  from  infection. 


THE  BLOOD  CLOT  IN  THE  MANAGEMENT  OF 
DEAD  SPACES  IN  THE  TREAT- 
MENT OF  WOUNDS 


THE  TREATMENT  OF  WOUNDS  WITH  ESPECIAL  REFERENCE 

TO  THE  VALUE  OF  THE  BLOOD  CLOT  IN  THE 

MANAGEMENT  OF  DEAD  SPACES " 

CONTENTS 

I.  Unclassified  Operations   77 

II.  Operations  for  Tuberculosis  of  Bones  and  Joints 83 

III.  Excision  of  Tuberculous  Lymphomata 85 

IV.  Operations  for  Carcinoma  of  the  Breast 87 

V.  Operations  for  the  Radical  Cure  of  Inguinal  Hernia  in  the  Male 89 

VI.  Amputations  of  the  Thigh 91 

VII.  Arthrodesis  for  Paralytic  Flail-Joints 91 

VIII.  Trendelenburg-Hahn  Operation  for  Flat  Foot 92 

IX.  Operations  for  Ununited  Fractures 92 

X.  Operations  for  Fractures  of  the  Patella 93 

XI.  Osteotomy  for  Bow  Legs 93 

XII.  Incision  and  Irrigation  of  Joints  for  Gonorrhoeal  Arthritis 94 

XIII.  Extirpation  of  Inguinal  Glands  for  Gonorrhoeal  Adenitis 94 

XIV.  Operations  for  Syphilis  of  Bones 95 

XV.  Necrotomies  and  Operations  for  Bone  Abscesses 96 

XVI.  Extirpation  of  Varicose  Veins  of  the  Leg  and  Thigh 98 

XVII.  Operations  for  the  Removal  of  Cysts  and  New  Growths 99 

To  drain  or  to  obliterate  with  the  greatest  care  all  of  the  dead  spaces  of 
a  ■wound  is  still  an  almost  universally  accepted  precept  of  surgery;  and 
surgeons  have  a  wholesome  fear  of  the  presence  of  blood  in  wounds. 

Having  referred  to  the  attempts  of  Maas,  Neuber  and  others  to  dispense 
with  the  use  of  drainage  tubes,  Kiister 2  expressed  himself  on  the  subject  of 
blood  in  wounds  as  follows :  "  Moreover,  it  soon  became  evident  that  the 
presence  of  blood  in  any  wound  represented  a  great  danger,  and  after  a 
while  one  seldom  heard  of  any  such  experiments  " — experiments  to  close 
a  wound  without  providing  for  its  drainage  or  for  the  obliteration  of  its 
dead  spaces. 

Von  Bergman,3  in  an  address  which  he  delivered  on  the  antiseptic  treat- 
ment of  wounds  a  few  years  ago,  says : 

"  That  organic  material  which  with  the  greatest  ease  becomes  the  seat  and 
essential  part  of  putrefactive  processes  is  the  blood,  which  streams  or  trickles 

"Johns  Hopkins  Hosp.  Rep.,  Bait.,  1890-91,  ii,  255-314.  (Reprinted.) 

Also:   Maryland  M.  J.,  Bait.,  1891,  xxiv,  529-533. 

*E.  Kiister,  Ueber  die  Anwendung  versenkter  Nahte.  Archiv.  fur  klin.  Chirurgie, 
1884,  Bd.  xxxi,  Heft  1,  S.  133. 

3Schede,  Ueber  die  Heilung  von  Wunden  unter  dem  feuchten  Blutschorf.  Ver- 
handlungen  der  deutschen  Gesellschaft  fiir  Chirurgie,  1886,  S.  65. 

71 


72  THE  BLOOD  CLOT 

from  the  divided  vessels  of  a  wound  and  collects  in  its  deeper  parts,  par- 
ticularly in  its  recesses  and  pockets.  Since  it  is  the  business  of  the  surgeon 
to  avoid  doing  anything  which  could  give  rise  to  decomposition  in  a  wound, 
it  should  be  his  care  to  provide  for  the  exclusion  of  a  fluid  so  prone  to  de- 
compose, one  of  the  most  important  if  not  the  most  important  of  the  achieve- 
ments of  antiseptic  surgery 

"  Formerly,  so  long  as  one  regarded  the  blood  as  the  plastic  material 
which  fills  the  holes,  as  the  glue  and  cement  which  should  stick  together  the 
edges  of  the  wound,  its  presence  seemed  not  only  good  but  desirable — now, 
since  one  knows  that  the  most  feared  and  most  dangerous  wound  diseases 
arise  from  its  decomposition,  one  struggles  with  all  one's  might  to  keep  the 
wound  freed  from  it.  The  surgeon,  who  has  not  arrested  the  bleeding  with 
the  most  scrupulous  care,  will  in  vain  look  for  results  for  success  with  his 
antiseptic  technique." 

Lister  has  done  more  than  any  one  perhaps  to  perpetuate  this  great  fear — 
the  fear  of  blood  in  wounds — of  prae-antiseptic  times.  For  twenty-three 
years  the  eyes  of  every  surgeon  have  been  turned  towards  Lister,  who  has 
rarely  lost  an  opportunity  to  emphasize  the  importance  of  wound  drainage. 
His  efforts  are  still  directed  to  the  best  means  of  taking  care  of  the  dis- 
charges from  wounds — to  the  perfection  of  a  dressing.  In  1875  *  he  ex- 
pressed himself  on  the  subject  of  drainage  as  follows : 

"  Two  days  later,  or  six  days  after  the  operation,  the  pain  in  the  limb,  of 
which  he  had  complained  at  the  last  dressing,  had  left  him ;  but  a  consider- 
able serous  stain  being  still  found  on  the  gauze,  the  drainage-tube  was  con- 
tinued, though  shortened  by  cutting  off  a  piece  from  the  deeper  end." 

Two  days  later : 

"  The  wound  being  dressed  the  line  of  incision  was  found  entirely  healed, 
except  at  the  point  occupied  by  the  drainage  tube,  and  the  serous  stain  on 
the  dressing  was  so  much  diminished  that  I  reduced  the  little  tube  to  a 
quarter  of  an  inch  in  length,  and  allowed  three  days  to  pass  before  the  next 
dressing.  On  then  exposing  the  wound,  however,  I  was  disappointed  to  find 
the  serous  stain  on  the  gauze  fully  as  great  as  on  the  last  occasion,  and 
pressure  on  the  skin  in  the  vicinity  of  the  wound  caused  a  drop  of  clear 
serum  to  escape.  This  had  never  been  seen  before  and  implied  that  the 
shortened  drainage  tube  had  not  been  answering  its  purpose  completely,  but 
had  permitted  a  certain  amount  of  serum  to  accumulate;  and  slight  as  this 
accumulation  was,  I  knew  from  experience  that  it  was  enough  to  perpetuate 
serous  oozing  by  the  tension  which  it  occasioned.  I  therefore  substituted 
for  the  short  drainage  tube  another  of  the  same  calibre,  but  twice  as  long — 
viz.,  half  an  inch,  being  as  deep  as  it  could  be  passed  without  violence,  and 
dressed  again  in  two  days.  The  result  was  such  as  I  had  hoped.  There  was 
an  almost  entire  absence  of  serous  stain  on  the  gauze,  and  nothing  could  be 
pressed  out  of  the  tube,  which  was  now  again  slightly  shortened.  The  dress- 
ing was  then  Left  untouched  for  four  days,  when  the  drainage  tube  was  found 

4  Lancet,  1875,  p.  436. 


THE  TREATMENT  OP  WOUNDS  73 

lying  out  of  the  wound,  having  been  forced  out  by  the  consolidation  going 
on  in  the  interior.  There  was  almost  no  stain  on  the  gauze,  and  nothing 
could  be  pressed  out  of  the  orifice  where  the  tube  had  been.  But  to  return 
to  the  point  which  this  case  is  intended  to  illustrate — viz.,  the  value  of  the 
drainage  tube  in  the  later  stages  of  wounds.  Supposing  that  instead  of 
substituting  a  longer  tube  for  the  shorter  one  on  the  eighth  day  after  the 
operation,  when  a  little  serum  was  found  to  have  accumulated,  I  had  then 
given  up  the  use  of  the  tube  altogether,  the  possibility  is  that  by  the  time  of 
the  next  dressing  the  outlet  at  the  integument  having  become  partially 
occluded  by  granulation  and  contraction,  a  greater  amount  of  serum  would 
have  been  pent  up  in  the  cavity,  and  in  course  of  time  the  additional  ten- 
sion so  occasioned  would  have  led  to  suppuration  and  to  the  opening  up  of 
the  nearly  cicatrised  wound." 

In  1866/  at  the  very  beginning  of  his  experiments  with  carbolic  acid — 
at  his  third  case — he  described  the  organization  of  a  small  blood  clot.  He 
observed  the  case — a  compound  fracture  of  the  leg — with  an  intense  interest. 
I  shall  quote  from  his  account  of  the  case  that  part  which  relates  to  the 
organization  of  the  blood  clot. 

"  On  the  7th  of  June,  nearly  three  weeks  after  the  accident,  an  observa- 
tion of  much  interest  was  made.  I  was  detaching  a  portion  of  the  adherent 
crust  from  the  surface  of  the  vascular  structure  into  which  the  extravasated 
blood  beneath  had  been  converted  by  the  process  of  organization,  when  I 
exposed  a  little  spherical  cavity  about  as  big  as  a  pea,  containing  brown 
serum,  forming  a  sort  of  pocket  in  the  living  tissues,  which,  when  scraped 
with  the  edge  of  a  knife,  bled  even  at  the  very  margin  of  the  cavity.  This 
appearance  showed  that  the  deeper  portions  of  the  crust  itself  had  been 
converted  into  living  tissue,  for  cavities  during  the  process  of  aggregation, 
like  those  with  clear  liquid  contents  in  a  Gruyere  cheese,  occur  in  the 
grumous  mass  which  results  from  the  action  of  carbolic  acid  upon  blood; 
and  that  which  I  had  exposed  had  evidently  been  one  of  these,  though  its 
walls  were  now  alive  and  vascular. 

"  Thus  the  blood  which  had  been  acted  upon  by  carbolic  acid,  though 
greatly  altered  in  physical  characters,  and  doubtless  chemically  also,  had  not 
been  rendered  unsuitable  for  serving  as  pabulum  for  the  growing  elements 
of  new  tissue  in  its  vicinity." 

Although  perfectly  familiar  with  the  organization  of  the  blood  clot  it  has, 
apparently,  never  occurred  to  Lister  to  make  a  systematic  effort  to  utilize 
the  blood  clot  and  to  imitate  nature's  method  of  disposing  of  the  dead  spaces 
in  wounds. 

He  has  taught  us  what  can  be  done  under  the  cover  of  antiseptics.  One 
may  maltreat  the  tissues  to  any  extent — mutilate  the  wound  during  the 
operation  in  every  possible  way,  cut  off  by  ligatures  the  circulation  in  large 
masses  of  tissue,  produce  extensive  areas  of  superficial  necrosis  by  irrigation 

5  Lancet,  1867,  p.  328. 


74  THE  BLOOD  CLOT 

with  antiseptic  solutions,  stuff  the  wound  with  gauze  and  drainage  tubes, 
tear  out  the  stuffing  and  with  it  the  granulations  which  have  grown  into  it, 
restuff,  etc. — and  still  the  wound  may  heal  without  suppuration,  without 
septic  inflammation,  and  in  a  way  which  is,  perhaps,  altogether  satisfactory 
to  the  surgeon. 

But  now  that  wound  infection  is  for  many  surgeons  almost  a  thing  of  the 
past,  we  may  ask  ourselves  if,  after  all,  our  wounds  are  ideal  wounds.  One 
naturally  hesitates  to  attempt  to  give  one's  notion  of  an  ideal  wound.  His 
ideal  wound  of  today  may  not  be  his  ideal  wound  of  next  year  or  even  of 
tomorrow.  I  conceive  an  ideal  wound  to  be  one  which  immediately  after 
the  operation  is  reduced  to  the  condition  of  a  nonpenetrating  subcutaneous 
wound,  and  which  is  as  free  as  this  is  from  the  dangers  of  infection.  By  a 
"  nonpenetrating  "  wound  I  mean  one  in  which  the  skin  is  not  penetrated 
and  I  use  the  term  nonpenetrating  because  the  penetrating  wounds  which 
used  to  be  made  in  tenotomy,  joint  and  other  operations  were  called  sub- 
cutaneous wounds.  A  wound  which  has  been  irrigated  with  solutions  of 
carbolic  acid,  corrosive  sublimate,  or  other  disinfectants  labors  under  the 
disadvantage  of  a  more  or  less  extensive  area  of  superficial  necrosis  from 
which  the  subcutaneous  wound  is  free.  The  subcutaneous  wound  is  not  ex- 
posed to  the  dangers  which  attend  the  introduction  of  drainage  tubes,  liga- 
tures and  sutures,  nor  to  the  greatest  of  all  dangers  for  the  surgeon's  wound, 
that  of  infection  from  the  hands  of  the  operator  and  his  assistants.  The 
drainage  tube  is  still  one  of  the  chief  features  of  the  modern  treatment  of 
wounds  despite  the  systematic  efforts  of  many  surgeons  for  the  past  ten  or 
more  years  to  dispense  with  its  use. 

Among  the  first  to  propose  a  method  for  securing  the  healing  of  wounds 
without  drainage  tubes  was  Kocher.*  He  recommended  a  secondary  suture. 
His  method  was  complicated,  necessitated  several  dressings  and  a  second 
operation,  was  annoying  to  the  patient  and  exposed  the  wound  unnecessarily 
often  to  the  dangers  of  infection. 

In  1884  there  appeared  from  Neuber7  a  valuable  contribution  to  the 
subject  of  the  abolishment  of  wound  drainage.  He  attached  great  impor- 
tance to  the  complete  obliteration  of  all  the  dead  spaces  in  wounds,  recom- 
mended for  irrigation  a  sterilized  0.6  per  cent  salt  solution,  and  provided 
for  drainage  by  "  canalization  "  and  by  loose  stitching.  For  the  obliteration 
of  dead  spaces  he  had  at  his  disposal  the  following  means :  compression  from 
without,  buried  sutures,  inverting  stitches,  flap  implantations  and  firm  coap- 
tation of  the  resected  ends  of  bones. 

•  Ueber  die  einfachsten  Mittel  zur  Erzielung  einer  Wundheilung  durch  Verklebung 
ohne  Drainrohren.  Th.  Kocher.  Volkmann's  Sammlung  klin.  Vortnige.  No.  224. 

T  Vorschlage  zur  Beseitigung  der  Drainage  fiir  alle  frischen  Wunden.  G.  Neuber. 
Kiel,  1884. 


THE  TREATMENT  OF  WOUNDS  75 

In  the  same  year  Kiister 8  published  his  well  known  article  on  the  employ- 
ment of  buried  sutures. 

Impressed  by  the  work  of  Kiister,  Xeuber  and  others  and  entertaining 
with  them  the  same  fears  of  blood  in  wounds,  it  was  my  practice  for  several 
years  to  attempt  with  the  utmost  care  to  obliterate  the  dead  spaces  in  wounds. 
The  results  were  gratifying  but  the  technique  was  often  very  tedious.  For 
example,  after  an  amputation  of  the  thigh  it  would  not  infrequently  take  an 
hour  to  obliterate  thoroughly  all  the  dead  spaces.  The  mechanical  problems 
were  sometimes  quite  difficult,  and  one  was  perpetually  annoyed  by  the  fear 
that  he  might  strangulate  the  tissues  included  in  the  sutures.  After  a  time 
I  became  convinced  that  it  was  impossible  to  obliterate  thoroughly  all  the 
dead  spaces  in  some  wounds,  and  I  observed  that  wounds  in  which  the  dead 
spaces  were  not  obliterated  healed  throughout  by  first  intention  just  as 
regularly  as  did  the  other  wounds.  I  was  therefore  quite  prepared  to  wel- 
come Schede's  article  on  the  healing  of  wounds  under  the  moist  blood  scab. 
This  contribution  of  Schede's '  I  believe  to  be  the  greatest  which  has  been 
made  to  the  technique  of  surgery  since  the  introduction  of  antiseptic  meth- 
ods by  Lister. 

That  Schede  was  impressed  by  the  importance  of  the  communication 
which  he  has  made  one  may  infer  from  his  introduction. 

He  says : 

"  I  am  fully  aware  that  it  is  a  thankless  task  to  come  once  more  before 
this  august  body  to  advocate  a  new  method  of  treating  wounds,  and  surely 
I  should  not  have  the  courage  to  do  so  if  I  did  not  believe  that  what  I  have 
to  communicate  to  you  today  deserves  because  of  its  essential  importance 
to  occupy  a  higher  plane  than  the  ordinary  modifications  of  the  antiseptic 
wound  dressing,  and  if  I  were  not  firmly  convinced  that  you  will  recognize 
in  what  I  have  to  say  a  real  contribution  to  our  science It  has  re- 
quired but  a  short  experience  with  antiseptic  surgery  to  enable  us  with 
astonishment  to  recognize  that  even  very  large  blood  clots  in  open  wounds 
do  not  necessarily  undergo  destruction  and  decomposition,  that  they  do  not 
necessarily  give  rise  to  inflammation  and  accidental  diseases,  but  that  they 
can  take  on  changes  which  one  may  designate  as  '  organization  of  the  blood 
clot '  and  which  one  can  compare  with  the  conversion  of  the  thrombus  in 
ligated  blood  vessels." 

The  immortal  John  Hunter  was  many  years  in  advance  of  his  times 
when  he  expressed  himself  on  scabbing  and  the  organization  of  the  blood 
clot  as  follows : 

"  In  many  deep-seated  wounds,  where  all  the  parts  have  remained  in  con- 
tact, those  underneath  will  unite  much  better  if  the  surface  be  allowed  to 

8E.  Kiister,  loc.  cit. 

*  M.  Schede,  Ueber  die  Heilung  von  Wunden  unter  den  feuchten  Blutschorf .  Ver- 
handlungen  der  deutschen  Gesellschaft  fur  Chirurgie,  1886. 


76  THE  BLOOD  CLOT 

scab.  Some  compound  fractures  (more  especially  where  the  external  wound 
is  very  small)  should  be  allowed  to  heal  in  the  same  way;  for  by  permitting 
the  blood  to  scab  upon  the  wound,  either  by  itself  or  when  soaked  in  lint, 
the  parts  underneath  will  unite,  the  blood  under  the  scab  will  become  vas- 
cular, and  the  union  will  be  complete  even  when  the  parts  are  not  in  con- 
tact  Many  wounds  ought  to  be  allowed  to  scab  in  which  this  process 

is  now  prevented;  and  this  arises,  I  believe,  from  the  conceit  of  surgeons 
who  think  themselves  possessed  of  powers  superior  to  nature,  and  therefore 
have  introduced  the  practice  of  making  sores  of  all  wounds/' 

In  1832  Wardrop  10  reported  a  remarkable  case  of  healing  under  a  scab. 
The  wounded  surface  was,  he  said,  the  largest  that  he  had  ever  beheld. 
It  arose  from  the  ablation  of  a  diseased  breast.  The  wound  healed  under  a 
crust  of  blood  which  was  not  disturbed  for  thirty  days. 

Volkmann  u  has  observed  the  blood  clot  remain  in  the  clefts  of  bone  for 
six  weeks  and  more  without  becoming  fluid,  without  undergoing  decomposi- 
tion and  without  causing  any  wound  disturbance,  and  advises  that  it  be 
left  undisturbed.  We  are  indebted  to  him  for  the  most  classical  description 
of  the  macroscopic  changes  which  take  place  in  the  blood  clot  of  an  aseptic 
open  wound.  He  depicts  the  clot  as  black  and  glistening  and  apparently 
unchanged  for  six  or  eight  days,  then  as  consumed  by  granulations  or 
gradually  shrinking  and  changing  color  from  black  to  a  leather  and  then 
to  an  orange  tint  and  forming  at  last  a  moist  scab  which  drops  off  when 
cicatrization  is  complete.  But  Schede  was  the  first  to  take  advantage  sys- 
tematically of  the  little  understood  properties  of  the  blood  clot.  He  re- 
garded the  blood  as  merely  a  plastic  material  possessed  of  high  powers  of 
organization.  From  experiments  of  Nuttall,  Pr'udden,  Buchner,  Lubarsch, 
Stern  and  others  we  know  that  the  blood  possesses  disinfectant  properties 
toward  certain  species  of  bacteria.  Human  blood  serum  does  not  appear 
to  be  injurious  to  the  multiplication  of  the  staphylococci  and  streptococci 
of  suppuration,  so  that  we  cannot  attribute  the  beneficial  results  obtained 
by  healing  under  the  blood  clot  to  any  direct  disinfectant  properties  of  the 
blood  upon  the  pyogenic  micrococci,  but  such  properties  may  come  into 
consideration  in  the  prevention  of  some  other  forms  of  wound  infection. 

10  Lancet,  1832-3.  ii,  653. 
u  Beitriige  zur  Chirurgie. 


THE  TREATMENT  OF  WOUNDS  77 

SUMMARY  OF  ALL  OF  THE  WOUNDS  TREATED  WITHOUT  DRAINAGE 

AND  WITHOUT  DEAD  SPACE  OBLITERATION— 

"  BLOOD  CLOT  WOUNDS  " 

From  the  Opening  of  the  Hospital  in  May,  1SS9,  to  June  1,  1890 

I.  Unclassified  Operations    25 

II.  Operations  for  Tuberculosis  of  Bones  and  Joints 10 

III.  Excision  of  Tuberculous  Lymphomata 10 

TV.  Operations  for  Carcinoma  of  the  Breast 13 

V.  Operations  for  the  Radical  Cure  of  Inguinal  Hernia  in  the  Male 8 

VI.  Amputations  of  the  Thigh 2 

VII.  Arthrodesis  for  Paralytic  Flail-Joints 5 

VIII.  Trendelenburg-Hahn  Operation  for  Flat  Foot 2 

IX.  Operations  for  Ununited  Fractures 2 

X.  Operations  for  Fractures  of  the  Patella 2 

XL  Osteotomy  for  Bow  Legs 3 

XII.  Incision  and  Irrigation  of  Joints  for  Gonorrhoeal  Arthritis 3 

XIII.  Extirpation  of  Inguinal  Glands  for  Gonorrhoeal  Adenitis 6 

XIV.  Operations  for  Syphilis  of  Bones 2 

XV.  Necrotomies  and  Operations  for  Bone  Abscesses 11 

XVI.  Extirpation  of  Varicose  Veins  of  the  Leg  and  Thigh 4 

XVII.  Operations  for  the  Removal  of  Cysts  and  New  Growths 14 

122 

Note. — There  were  no  deaths.  Of  the  clean  wounds,  two  suppurated  primarily; 
vid.  pp.  82  and  83. 

I.  Unclassified  Opeeatioxs 

Twenty-five  cases.  Nos.  2,  76,  78,  98,  105,  145,  160,  226,  241,  243,  284, 
314,  346,  360,  377,  398,  421,  426,  445,  451,  470,  473,  479,  483,  and  484. 

Typical  healing  in  22  of  the  cases.  Primary  suppuration  in  two  cases, 
Nos.  105  and  160.  Haemorrhage  in  one  case,  No.  473,  which  necessitated  the 
opening  up  of  the  wound. 

Example  1. — Exsection  of  an  elbow  which  had  been  crushed  by  the 
wheels  of  a  horse  car.  Typical  healing. — No.  398.  Dominick  Cassine,  col- 
ored, aet.  45,  was  admitted  to  the  hospital  March  17,  1890,  within  thirty 
minutes  of  the  time  of  the  accident.  He  had  fallen  from  the  front  platform 
of  a  horse  car.  At  least  one  of  the  wheels  of  the  car  had  passed  over  his  left 
elbow.  The  injury  sustained  was  about  as  great  as  is  possible  in  such  an 
accident.  The  elbow  felt  like  a  bag  of  bones.  The  skin  was  broken  through 
in  three  places  and  was  badly  contused  on  the  arm  and  forearm  as  well  as 
about  the  elbow. 

Operation. — The  existing  wounds  were  enlarged;  lacerated  pieces  of  the 
triceps  muscle,  fragments  of  the  lower  end  of  the  humerus  and  the  olecranon 
process  of  the  ulna  were  removed.  Three  or  four  longitudinal  incisions 
were  made  through  the  skin  which  was  undermined  in  all  directions.  The 
oozing  of  blood,  which  Mas  considerable,  was  purposely  not  checked.  The 
entire  upper  extremity  was  placed  first  in  a  solution  of  corrosive  sublimate 


78  THE  BLOOD  CLOT 

(1-1000)  for  about  three  minutes,  and  then  in  a  solution  of  carbolic  acid 
(1-30)  for  about  five  minutes.  The  wound  was  then  allowed  to  fill  with 
blood.  No  stitches  were  taken.  The  arm,  the  elbow,  and  the  upper  part  of 
the  forearm  were  wrapped  with  strips  of  protective  about  one  inch  wide. 
Iodoformized  gauze  was  placed  over  the  protective,  and  over  all  a  very  large 
dressing  of  sterilized  gauze.  The  arm  was  put  up  in  an  extended  position. 
The  blood  clot  which  occupied  the  wound  must  have  been  as  large  as  a  man's 
fist. 

March  21st. — The  patient's  pulse  and  temperature  have  been  about  nor- 
mal ever  since  the  operation.  The  highest  temperature  was  38.1  °  C.  The 
wound  is  dressed,  first,  because  the  patient  complains  of  a  little  pain  in  his 
fingers,  and  second,  to  satisfy  our  curiosity  about  the  condition  of  the  blood 
clot.  The  elbow  is  in  excellent  condition.  Each  one  of  the  cuts  is  filled  with 
a  protruding  blood  clot. 

April  2d. — The  wound  is  redressed.  The  organization  of  the  blood  clot 
seems  to  be  complete.  The  protruding  portions  of  it  are  bright  red  and 
bleed  when  gently  scratched. 

April  12th. — The  patient  is  discharged  well. 

October  14th. — The  patient  presents  himself  at  the  hospital  for  examina- 
tion. The  elbow  is  a  remarkably  good  one.  The  patient  can  extend,  flex, 
pronate  and  supinate  the  left  elbow  perfectly.  He  cannot,  however,  execute 
these  movements,  particularly  extension,  with  quite  the  normal  force. 

Example  2. — Extirpation  of  the  head  of  the  femur  for  ununited  intra- 
capsular fracture  of  the  neck  of  the  femur.  Typical  healing. — No.  284. 
Henry  Franklin,  aet.  50,  was  admitted  to  the  hospital  January  16,  1890. 
In  April,  1889,  patient  fell  from  a  ladder  and  sustained  a  fracture  of  the 
neck  of  the  femur.  The  physician  who  treated  him  did  not  at  first  recog- 
nize the  nature  of  the  injury,  and  after  keeping  him  in  bed  for  three  weeks 
without  a  splint  advised  him  to  get  up  and  walk.  This  the  patient  was  un- 
able to  do.  Then  the  physician  put  on  a  splint  of  some  kind  and  kept  the 
patient  in  bed  for  five  weeks.  At  present  the  patient  can,  for  a  moment, 
bear  his  weight  on  his  left  leg.  It  gives  him  great  pain  to  do  so.  He  refers 
the  pain  to  the  upper  part  of  his  thigh  and  particularly  to  his  knee.  The  pain 
with  time  has  increased  rather  than  diminished. 

The  patient  says  that  he  prefers  to  die  than  to  live  as  he  is  and  is  willing 
to  expose  himself  to  the  risks,  however  great,  of  any  operation  which  offers 
to  him  a  chance  of  being  benefited. 

Examination. — The  leg  is  adducted  and  rotated  outwards.  The  real 
shortening  is  about  5  cm.,  the  apparent  shortening  8  cm.,  and  the  measured 
shortening  (measured  from  the  anterior  superior  spine  of  the  ilium  to  the 
external  malleolus)  3.5  cm.  The  femur  rotates  on  its  own  long  axis.  Diag- 
nosis :  intracapsular  fracture  of  the  neck  of  the  femur. 

Operation,  January  17,  1S90. — External  longitudinal  incision  about  22 
cm.  long.  The  great  trochanter  was  chiseled  off  flush  with  the  bottom  of  the 
digital  fossa.  The  loose  head  of  the  femur  was  found  in  position  in  the 
acetabulum  and  removed.  It  was  slightly  excavated.  The  ligamentum  teres 
had  been  ruptured  and  not  a  trace  of  it  was  to  be  seen  on  the  head  of  the 
femur.  The  neck  of  the  femur  had  been  absorbed.  The  divided  muscles 
were  loosely  stitched  together  by  a  few  buried  silk  stitches.   Inasmuch  as  a 


THE  TREATMENT  OF  WOUNDS  79 

considerable  amount  of  blood  continued  to  ooze  from  the  deeper  parts  of 
the  wound  I  introduced  a  narrow  strip  of  gauze  to  the  bottom  of  the  wound — 
into  the  capsule  of  the  joint.  I  feared  that  the  blood  might  be  dammed  up 
by  the  tense  tissues  about  the  joint.  The  wound  was  closed  by  buried  skin 
sutures  and  dressed  with  gauze. 

January  18th. — The  gauze  plug  is  removed  and  the  large  dead  space 
which  it  occupied  allowed  to  fill  with  blood. 

February  8th. — The  wound  is  dressed.  It  is  typically  healed.  A  Volk- 
mann's  extension  apparatus  is  applied. 

April  12th. — Patient  is  allowed  to  walk  with  crutches. 

October  1st. — Patient  walks  very  well  and  without  pain  but  still  wears 
a  Volkmann's  side  splint.  He  is  greatly  pleased  with  the  result  of  the 
operation. 

Example  3. — Operation  for  the  cure  of  deformity  resulting  from  a  sub- 
luxation and  fracture  of  the  internal  cuneiform  bone.    Typical  healing.— - 

No.  426.  Miss was  admitted  to  the  hospital  April  15,  1890.  Eighteen 

months  ago  the  horse  which  she  was  riding  fell  and  rolled  upon  her  left  foot 
which  was  caught  in  the  stirrup.  The  surgeon  in  attendance  reduced  more 
or  less  completely  a  dislocation  of  some  kind  which  had  caused  a  deformity 
conspicuous  enough  to  attract  the  attention  of  the  patient. 

Ten  days  after  the  accident,  while  attempting  to  walk  on  crutches,  the 
patient  slipped  and  fell  and  reproduced  the  original  deformity.  The  dis- 
location was  again  reduced,  and  a  few  days  later  again  by  accident  produced 
and  once  more  reduced.  In  about  four  months  patient  began  to  walk,  and 
in  a  little  more  than  a  year  was  able  to  dance.  About  three  months  ago  the 
pain  in  her  foot,  which  for  a  time  had  almost  vanished,  returned,  and  since 
its  return  has  steadily  increased.  Now  it  is  severe  enough  to  incapacitate 
her  from  walking. 

Examination. — The  internal  cuneiform  bone  is  subluxated  inwards  aDd 
much  enlarged.  The  foot  has  lost  its  arch  and  is  abducted  at  the  scaphoid- 
cuneiform  articulation. 

Operation. — The  internal  cuneiform  bone  was  fully  exposed  by  a  long 
internal  longitudinal  incision.  It  was  found  to  have  been  fractured,  as  well 
as  subluxated.  The  fracture  had  united  with  the  formation  of  considerable 
callus.  The  internal  cuneiform  bone  with  the  exception  of  a  small  disc  which 
included  the  anterior  surface  of  the  bone  was  chiseled  out.  It  was  necessary 
to  exert  a  great  deal  of  force  to  restore  the  foot  to  its  proper  position.  The 
cavity  resulting  from  the  extirpation  of  the  internal  cuneiform  bone  was 
allowed  to  fill  with  blood.  The  wound  was  closed  with  buried  skin  sutures, 
covered  with  gutta-percha  tissue  and  dressed  with  gauze.  The  foot  was 
maintained  in  the  equino-varus  position  by  a  plaster  of  Paris  splint.  The 
small  disc  of  the  internal  cuneiform  bone  was  left  with  the  hope  that  from 
it  the  blood  clot  might  be  converted  into  bone. 

April  18th. — The  wound  is  dressed  and  has  united  perfectly.  The  blood 
clot  seems  quite  firm.  A  new  and  close  fitting  plaster  of  Paris  splint  is 
applied. 

May  18th. — The  foot  seems  to  be  in  perfect  position.  The  blood  clot  feels 
already  as  hard  as  bone.   The  patient  is  permitted  to  walk  on  crutches. 


80  THE  BLOOD  CLOT 

November  1st. — The  position  of  the  foot  is  still  perfect.  The  patient  can 
walk  many  miles  without  the  slightest  discomfort.  She  believes  that  the 
right  foot  is  as  strong  and  as  perfect  as  the  left  one. 

Example  4. — Operation  for  the  cure  of  pronation  and  drop  wrist,  the 
result  of  a  fracture  of  the  radius  and  ulna.  Typical  healing. — No.  484. 
Conrad  Pilgrim,  aet.  18,  was  admitted  to  the  hospital  May  27,  1890.  Four 
months  ago  patient  broke  both  bones  of  his  left  forearm  about  8  cm.  above 
the  wrist.  When  the  splints  were  removed  patient  was  confident  that  his 
arm  had  not  been  properly  set.  He  has  not  been  able  to  extend  the  wrist  or 
do  any  but  the  lightest  work  since  the  accident. 

Examination. — Patient's  left  forearm  is  strongly  pronated  and  cannot  be 
supinated.  He  carries  his  hand  in  the  drop  wrist  position  but  is  able  to 
extend  his  wrist  feebly.  I  have  several  times  noticed  this  tendency  to  drop 
wrist  in  fractures  of  the  forearm  which  have  united  in  the  position  of  ex- 
treme pronation.  The  forearm  being  pronated  the  hand  must  drop  unless 
held  up  voluntarily  by  the  patient.  The  patient  soon  wearies  of  the  constant 
effort  and  the  hand  falls. 

Operation,  May  SO,  1890. — Lateral  incisions,  10  cm.  long,  over  radius 
and  ulna.  The  bones  which  were  not  adherent  to  each  other  were  chiseled 
through  at  about  the  junction  of  their  middle  and  lower  thirds.  The  lower 
fragments  were  rotated  outwards  with  considerable  force.  The  muscles 
which  resisted  the  outward  rotation  were  necessarily  twisted.  The  wound 
was  stitched  with  buried  skin  sutures,  covered  with  gutta-percha  tissue  and 
dressed  with  gauze.  The  forearm  was  flexed  on  the  arm  and  the  extreme 
supination  maintained  by  a  plaster  of  Paris  splint. 

June  10th. — The  dressing  is  removed.  The  wound  is  healed  throughout. 
The  arm  and  forearm  are  again  put  up  in  a  plaster  of  Paris  splint. 

October,  1890. — Patient  presents  himself  for  inspection.  He  can  pronate 
and  supinate  his  forearm  very  well ;  can  extend  his  wrist  as  forcibly  as  ever, 
he  thinks,  and  is  able  to  do  hard  work  of  all  kinds. 

Example  5. — Subtrochanteric  osteotomy  and  tenotomies  for  the  cure  of 
deformity  resulting  from  tuberculous  hip- joint  disease.  Typical  healing. — 
No.  445.  Charles  Love,  aet.  10,  was  admitted  to  the  hospital  May  1,  1890. 
Five  years  ago  the  patient  began  to  complain  of  pain  in  his  right  hip  and 
right  knee.  The  hip  soon  began  to  swell.  An  abscess  formed  quite  rapidly 
and  opened  spontaneously  in  several  places.  The  sinuses  persisted  for  two 
years  and  then  closed. 

Examination. — The  right  thigh  is  adducted,  rotated  in  and  flexed  at 
about  a  right  angle  to  the  body.  The  hip  is  not  dislocated.  The  anchylosis 
at  the  hip-joint  is  apparently  a  bony  one. 

Operation,  May  7,  1890. — Open  incision  of  the  adductor  muscles  and  of 
the  tensor  vaginae  femoris  muscle.  Subtrochanteric  osteotomy.  The  thigh 
could  then  be  extended  and  abducted.  The  wounds  were  loosely  closed  by 
buried  skin  sutures,  covered  with  gutta-percha  tissue  and  dressed  with 
gauze.  The  thigh  was  put  up  in  a  plaster  of  Paris  splint  in  an  extended 
and  strongly  abducted  position.  We  ordinarily  abduct  the  thigh  until  there 
is  apparent  lengthening  of  the  abducted  limb. 

May  81st. — The  original  dressing  is  removed.  All  the  wounds  are  per- 
fectly healed. 


THE  TREATMENT  OF  WOUNDS  81 

Example  6. — Exsection  of  a  portion  of  the  radius  and  of  the  ulna  for 
contraction  of  the  flexor  muscles  of  the  forearm.  Typical  healing. — No.  377. 
Clara  Albert,  aet.  30,  was  admitted  to  the  hospital  March  17,  1890.  When 
about  one  year  old  the  patient's  right  little  finger  was  crushed  in  the  cog- 
wheels of  a  sewing  machine.  The  wound  became  much  inflamed  and  was 
an  open  sore  for  six  or  more  weeks.  In  about  five  years  the  right  hand  had 
become  strongly  flexed  upon  the  forearm.  Two  years  later  the  patient  was 
operated  upon  and  was  compelled  to  wear  splints  for  three  or  four  years. 
In  a  short  time  the  hand  became  flexed  again  and  has  remained  so  ever 
since. 

Operation,  March  20,  1890. — A  transverse  dorsal  incision  about  4  cm. 
above  the  wrist  joint  was  made  through  the  skin  and  extensor  tendons  down 
to  the  bone.  About  3  cm.  of  the  radius,  of  the  ulna,  of  the  extensor  tendons 
and  of  the  skin  were  excised.  The  bones  were  sewed  together  with  strong 
silk.  The  skin  wound  was  united  by  buried  skin  sutures  of  fine  silk,  covered 
with  gutta-percha  tissue  and  dressed  with  sterilized  gauze.  The  arm,  fore- 
arm and  hand  were  encased  in  the  plaster  of  Paris  splint. 

April  7th. — The  wound  is  dressed.  It  has  healed  in  the  typical  way.  The 
patient  can  already  flex  and  extend  her  fingers. 

Example  7. — Arthrotomy  for  rupture  of  the  posterior  crucial  ligament. 
Typical  healing. — No.  346.  John  H.  Smith,  aet.  22,  was  admitted  to  the 
hospital  February  26,  1890.  About  four  weeks  ago  the  patient  was  sitting 
in  a  chair  with  his  legs  crossed  and  strongly  flexed.  Upon  suddenly  extend- 
ing them  he  "  felt  something  slip  "  in  his  left  knee  joint  and  found  himself 
unable  to  fully  extend  it.  With  the  assistance  of  a  cane  he  could  walk  with- 
out pain.  About  two  weeks  ago  while  manipulating  his  knee  he  unex- 
pectedly succeeded  in  straightening  it.  About  one  week  ago  from  a  misstep 
the  same  slipping  of  something  in  the  joint  and  the  flexion  of  the  joint 
recurred. 

Examination. — The  leg  is  flexed  on  the  thigh  at  an  angle  of  about  135°. 
There  is  a  little  fluid  in  the  knee  joint.  When  the  leg  is  strongly  flexed 
there  appears  to  be  an  almost  inappreciable  subluxation  forwards  of  the  head 
of  the  tibia.  On  forced  flexion  the  patient  complains  of  pain  which  he  refers 
to  the  articular  surface  of  the  outer  tuberosity  of  the  tibia.  On  forced 
extension  the  patient  refers  the  pain  to  about  the  centre  of  the  popliteal 
space. 

Operation,  February  29,  1890. — The  joint  was  freely  opened  by  a  long 
ante ro -internal  incision.  The  incision  was  curved  outwards  at  its  extremi- 
ties, its  lower  end  dividing  a  portion  of  the  ligamentum  patellae  and  its 
upper  end  some  of  the  fibres  of  the  vastus  internus  muscle.  The  joint  con- 
tained about  four  or  five  c.  cm.  of  a  clear  straw-colored  fluid  and  its  synovial 
membrane  was  considerably  injected.  The  posterior  crucial  ligament  was 
found  to  be  torn  away  from  its  attachment  to  the  outer  surface  of  the  in- 
ternal condyle  of  the  femur  and  to  have  carried  with  it  quite  a  large  piece 
of  bone  in  three  fragments.  Two  of  these  fragments  were  attached  to  the 
ligament.  The  other  fragment  was  loose  in  the  joint  and  had  made  for  itself 
a  depression  in  the  cartilage  covering  the  antero-external  surface  of  the 
internal  condyle  of  the  femur.  A  cavity  about  2.5  cm.  in  diameter  and  about 
7 


82  THE  BLOOD  CLOT 

0.5  cm.  deep  was  made  in  the  outer  side  of  the  internal  condyle  of  the  femur 
by  the  tearing  away  of  the  posterior  crucial  ligament.  Extension  of  the  leg 
had  been  prevented  by  the  impaction  of  one  of  the  fragments  of  bone  be- 
tween the  femur  and  tibia  at  the  back  part  of  the  joint.  With  the  liberation 
of  this  fragment  the  joint  could  be  extended.  The  posterior  ligament  was 
cut  away  at  its  tibial  attachment  and  removed.  The  wound  was  loosely 
closed  with  buried  sutures  of  the  muscle  and  skin,  covered  with  gutta-percha 
tissue  and  dressed  with  sterilized  gauze. 

March  2d. — The  wound  is  dressed.  It  has  healed  in  the  typical  way.  The 
patient  has  no  pain  and  the  leg  can  already  be  flexed  about  45°. 

March  23d. — The  patient  is  discharged  for  misdemeanor. 

Example  8. — Division  of  the  flexor  tendons  for  contracted  fingers. 
Typical  healing. — No.  243.  Joseph  Hettinger,  aet.  28,  was  admitted  to  the 
hospital  December  6,  1889.  Sixteen  months  ago  the  base  of  the  middle 
finger  and  the  tip  of  the  ring  finger  of  the  right  hand  were  crushed  by  cog 
wheels.  In  six  weeks  the  wounds  were  healed  but  the  injured  fingers  were 
strongly  flexed. 

Examination. — The  middle  and  ring  fingers  of  the  right  hand  are  flexed 
and  cannot  be  straightened.  The  tip  of  the  middle  finger  touches  the  palm 
of  the  hand,  and  the  tip  of  the  ring  finger  rests  on  the  middle  finger. 

Operation,  December  10,  1889. — A  triangular  flap  was  made  with  its  apex 
about  opposite  the  metacarpo-phalangeal  joint  as  in  Busch's  operation  for 
Dupuytren's  contraction.  The  contraction  of  the  fingers  was  found  to  be 
due  to  the  tendons  and  not  to  the  fascia.  Attempts  to  straighten  the  middle 
finger  produced  a  dislocation  forwards  of  the  distal  end  of  the  phalanx.  The 
flexor  tendons  of  the  middle  finger  were  divided  and  the  finger  was 
straightened.  In  the  gap  between  the  divided  ends  of  the  tendons  was  quite 
a  deep  hole.  This  hole  over  the  metacarpo-phalangeal  joint  and  the  base 
of  the  first  phalanx  was  allowed  to  fill  with  blood.  The  wound  was  left  wide 
open  and  covered  with  gutta-percha  tissue.  The  finger  was  bound  to  a 
narrow  hard  rubber  splint  and  dressed  with  gauze.  The  tendons  of  the  ring 
finger  were  not  divided,  for  the  flexion  of  this  finger  was  believed  to  be  due 
chiefly  to  that  of  the  middle  finger. 

January  6,  1890. — The  wound  is  dressed  before  the  Hospital  Medical 
Society.  The  blood  clot  which  fills  the  wound  to  the  level  of  the  skin  is 
almost  completely  organized.  The  centre  of  the  blood  clot  is  white,  but  in 
the  outer  zone  of  this  decolorized  and  opaque  portion  of  the  clot  may  be 
seen  with  the  naked  eye,  and  more  distinctly  with  the  lens,  the  pinkish  gray 
translucent  granulation  tissue. 

January  20th. — The  wound  has  healed  in  the  typical  way.  Both  the 
middle  and  ring  fingers  are  nearly  straight.  The  patient  can  already  flex 
his  middle  finger  a  little.  The  ring  finger  he  flexes  quite  well. 

Example  9. — Excision  of  the  supraorbital  nerve.  No.  105.  Primary  sup- 
puration of  the  wound. — The  wound  was  closed  with  celloidin.  The  haemor- 
rhage was  not  properly  checked;  and  no  provision  having  been  made  for 
the  escape  of  the  blood,  the  wound  became  distended  with  it  and  suppurated. 

I  am  quite  sure  that  the  suppuration  in  this  case  might  have  been  pre- 
vented if  we  had  opened  the  wound  enough  to  relieve  the  tension  of  it.   We 


THE  TREATMENT  OF  WOUNDS  83 

preferred  to  run  the  risk  of  being  compelled  to  use  the  case  to  demonstrate 
the  bad  effects  of  tension  in  a  wound.  At  one  time  we  would  have  referred 
the  suppuration  to  the  blood  in  the  wound,  and  not  to  the  tension. 

This  is  the  first  closed  wound  which  has  suppurated  since  the  opening 
of  the  hospital. 

Example  10. — Operation  for  dislocation  backwards  of  the  distal  row  of 
carpal  bones.  Suppuration  of  the  wound. — No.  160.  Jas.  W.  Plummer, 
aet.  55,  was  admitted  to  the  hospital  October  6,  1890.  Seventeen  weeks  ago 
he  fell  from  a  scaffold  and  struck  on  his  right  palm  and  hyper-extended 
wrist.  He  was  treated  by  a  physician  for  a  sprain.  For  three  or  four  weeks 
after  the  accident  he  suffered  great  and  almost  incessant  pain.  At  present 
the  slightest  motion  of  the  wrist  is  painful,  and  in  bad  weather  the  pain  is 
quite  constant  and  severe  enough  to  deprive  him  of  sleep. 

Operation,  October  7 ',  1889. — The  wrist  joint  was  exposed  by  two  dorsal 
longitudinal  incisions,  the  one  external,  the  other  over  the  dislocated  os 
magnum.  The  proximal  row  of  carpal  bones  was  subluxated  forwards,  far 
enough  to  allow  the  dislocated  os  magnum  to  articulate  with  the  radius. 
The  entire  distal  row  of  carpal  bones  was  dislocated  backwards  and  rested 
on  the  proximal  row.  The  os  magnum  had  been  fractured.  The  entire  car- 
pus was  excised  with  the  exception  of  the  trapezium  and  the  pisiform  bone. 
The  wound  was  stitched  and  dressed  as  usual.  For  ten  days  the  patient  was 
perfectly  comfortable,  and  his  temperature  was  about  normal. 

October  17th. — The  patient  complains  of  pain  in  the  upper  part  of  his 
forearm.   This  is  relieved  by  cutting  the  bandage  a  little. 

October  20th. — The  patient  again  complains  of  pain.  His  temperature 
is  normal.  The  dressing  is  removed.  The  wound  is  suppurating  and  the 
pus  has  burrowed  up  the  forearm  and  down  under  the  extensor  tendons  on 
the  back  of  the  hand.  This  is  the  second  undrained  wound  which  has  sup- 
purated since  the  opening  of  the  hospital  six  months  ago. 

II.  Opeeations  foe  Tttbeeculosis  of  Bones  and  Joints 

Ten  cases.   Typical  healing  in  all  of  the  cases. 

Shoulder:  1  case,  No.  356.  Elbow:  1  case,  No.  318.  Hip:  1  case, 
No.  50.  Knee :  3  cases,  Nos.  215,  364,  487.  Ankle :  4  cases,  Nos.  128,  148, 
191,  372. 

Example  1. — Exsection  of  the  head  of  the  humerus  and  extirpation  of 
the  capsule  of  the  shoulder  joint. — No.  356.  John  Kalb,  aet.  18. 

Operation,  March  6,  1890. — The  shoulder  joint  was  exposed  by  a  long 
anterior  vertical  incision.  The  capsule  of  the  joint  was  involved  in  the 
tuberculous  process  which  had  almost  perforated  it  in  one  or  two  places. 
The  head  of  the  humerus  was  removed.  In  it  were  three  large  and  many 
small  tuberculous  foci.  The  entire  capsule  was  excised.  The  scapula  was 
not  involved.  The  cartilage  covering  its  glenoid  cavity  was  perfectly  healthy. 
In  closing  the  wound  the  skin  only  was  sutured,  very  loosely  and  by  a  few 
interrupted  buried  skin  sutures  placed  far  apart. 

March  17th. — The  dressing  was  removed  at  a  meeting  of  the  Hospital 
Medical  Society.  The  wound  had  healed  primarily.   Here  and  there  between 


84  THE  BLOOD  CLOT 

the  sutures  were  small  areas  of  granulation  tissue.  At  the  upper  end  of  the 
wound  could  be  seen  the  surface  of  a  small  blood  clot. 

Example  2. — Exsection  of  the  elbow  joint. — No.  318.  John  Maloney, 
aet.  17.  Admitted  to  the  hospital  February  7,  1890.  Patient  has  had  a 
tuberculous  elbow  for  four  years.  There  is  now  a  sinus  over  the  olecranon 
which  communicates  with  the  joint.  There  are  scars  of  other  sinuses  which 
are  now  closed. 

Operation,  February  15,  1890. — The  olecranon  process  was  circumscribed 
by  a  parabolic  incision  into  the  joint.  From  the  top  of  this  incision  a  ver- 
tical incision  about  5  cm.  long  was  made  through  the  triceps  muscle.  The 
sinus  was  first  excised.  To  do  this  it  was  necessary  to  buttonhole  the  semi- 
circular flap.  The  cartilage  of  the  joint  had  been  almost  completely  de- 
stroyed. There  were  tuberculous  foci  in  the  olecranon  process  of  the  ulna 
and  in  the  condyles  of  the  humerus.  The  diseased  bone  was  removed  and 
the  capsule  of  the  joint  carefully  excised.  The  skin  wound  was  loosely  closed 
with  buried  skin  sutures  of  fine  black  silk.  Gutta-percha  tissue  was  placed 
over  the  line  of  the  sutures.  The  dressings  were  of  sterilized  gauze.  The 
joint  was  maintained  in  position  by  a  plaster  of  Paris  splint. 

March  Hth. — The  dressing  was  removed  at  a  meeting  of  the  Hospital 
Medical  Society.  Through  the  little  circular  hole  of  the  semicircular  flap 
projected  the  well  organized  blood  clot.   The  wound  had  healed  throughout. 

Example  3. — Partial  excision  of  the  knee  joint. — No.  215.  Mrs.  M., 
aet.  42,  was  admitted  November  13,  1889.  She  has  had  tuberculosis  of  the 
right  knee  for  several  years.  Until  recently  she  has  been  able  to  walk  with- 
out crutches. 

Operation,  November  27,  1889. — The  joint  was  opened  by  an  anterior 
semi-elliptical  incision.  It  was  filled  with  lenticular  "  rice  "  bodies,  and  a 
straw-colored  gelatinous  exudate.  The  tubercular  process  had  reduced  the 
patella  to  a  shell,  and  had  completely  undermined  and  almost  destroyed 
the  cartilage  covering  the  ends  of  the  bones.  There  was  a  large  tuberculous 
focus  in  the  head  of  the  tibia.  The  capsule,  the  crucial  ligaments  and  the 
semilunar  cartilages  were  excised.  The  ends  of  the  bones  were  shaved  with  a 
bone  knife,  and  the  tuberculous  focus  in  the  head  of  the  tibia  incompletely 
removed  by  a  sharp  spoon.  The  bones  were  held  in  position  by  strong  silk 
sutures.  The  skin  wound  was  closed  by  buried  skin  sutures  of  fine  silk. 
Gutta-percha  tissue  was  placed  over  the  wound.  The  limb  was  enveloped  in 
sterilized  gauze  dressings.   Over  all  was  applied  a  plaster  of  Paris  splint. 

December  2d. — The  wound  was  redressed  because  the  original  dressing 
had  become  soaked  with  urine.    The  wound  was  perfectly  healed. 

December  22d. — The  dressings  were  removed  and  the  extremity  was  put 
up  in  a  plaster  of  Paris  splint. 

May  1st. — There  is  no  sign  of  a  return  of  the  disease.  The  patient  is  free 
from  pain  and  has  been  walking  without  crutches  for  several  months. 

This  case  illustrates  what  I  have  repeatedly  observed,  viz.,  that  a  tuber- 
culous joint  may  be  perfectly  cured  even  when  the  diseased  tissue  has  not 
been  thoroughly  removed.  I  am  convinced  that  it  is  a  mistake  to  suppose 
that  one  must  thoroughly  remove  every  particle  of  the  tuberculous  tissue, 
in  order  to  arrest  the  tuberculous  process  in  bones  and  joints.    Surgeons 


THE  TREATMENT  OF  WOUNDS  85 

should  not  congratulate  themselves  upon  having  removed  all  of  the  tuber- 
culous tissue  whenever  there  is  no  return  of  the  disease.  It  is  impossible  to 
determine  with  the  naked  eye  the  limits  of  the  disease.  Of  this  fact  any  one 
who  carefully  controls  his  operative  work  with  the  microscope,  may  con- 
vince himself.  I  believe  it  is  an  accident  of  rare  occurrence  for  a  surgeon 
to  extirpate  absolutely  every  particle  of  the  tuberculous  tissue  of  a  joint, 
and  that  the  permanent  cures  which  so  frequently  result  from  operations 
upon  tuberculous  joints  require  an  explanation  quite  as  much  as  the  cases 
of  peritonaeal  tuberculosis  which  have  been  cured  by  laparotomy  require  it. 

Example  4. — Excision  of  the  ankle  joint. — No.  372.  Harry  Smith,  aet.  8, 
was  admitted  to  the  hospital  March  13,  1890.  Patient  has  a  tuberculous 
left  ankle.  Behind  and  a  little  above  the  external  malleolus  is  the  orifice  of 
a  sinus  which  communicates  with  the  joint. 

Operation,  March  21,  1890. — The  incision  which  began  over  the  fibula 
a  little  above  the  point  at  which  it  becomes  subcutaneous  was  continued 
along  the  posterior  border  of  the  external  malleolus,  and  around  the  tip  of 
the  malleolus  to  its  termination  over  the  base  of  the  fifth  metatarsal  bone, 
external  to  the  insertion  of  the  tendon  of  the  peroneus  tertius  muscle.  The 
tendons  of  the  peroneus  brevis  and  peroneus  longus  muscles  were  divided. 
The  foot  was  then  forcibly  extended  and  supinated  and  the  opposing  fasciae 
and  ligaments  divided.  The  supination,  extension  and  adduction  were  con- 
tinued until  the  joint  was  dislocated.  The  anterior  ligaments  were  divided 
from  within  outwards.  The  joint  was  filled  with  pale  and  flabby  tuberculous 
granulation  tissue.  The  external  malleolus  being  removed,  the  lining  of  the 
joint  was  carefully  excised.  The  cartilage  covering  the  lower  end  of  the 
tibia  had  been  dissected  up  by  the  tuberculous  process.  A  small  tuberculous 
focus  in  the  astragalus  was  chiseled  out.  Thin  lamellae  of  bone  were  sawed 
off  from  the  upper  surface  of  the  astragalus  and  the  lower  end  of  the  tibia. 
The  divided  peronei  tendons  were  sutured.  A  small  counter  opening  was 
made  at  the  inner  side  of  the  joint  to  guard  against  distension  of  the  joint 
with  blood.  The  wound  was  loosely  closed  with  buried  skin  sutures  of  fine 
silk,  covered  with  gutta-percha  tissue  and  dressed  with  sterilized  gauze. 
The  ankle  and  knee  joints  were  immobilized  by  a  plaster  of  Paris  splint. 

April  18th. — The  dressing  is  removed.  The  wound  has  healed  in  the 
typical  way.  There  is  a  small  round  granulating  spot  at  the  site  of  the 
counter  opening. 

III.  Excision  of  Tuberculous  Lymphomata 

Ten  cases.  Seven  cervical:  Nos.  91,  370,  389,  410,  425,  482,  and  490. 
Two  axillary:  Nos.  69  and  147.  One  inguinal:  No.  327.  Typical  healing 
in  all  of  the  cases. 

Example  1. — Excision  of  cervical  glands. — No.  425.  Thomas  Skinner, 
aet.  18,  was  admitted  to  the  hospital  April  17,  1890. 

Operation,  April  17,  1890. — The  principal  incision  extended  from  the 
left  mastoid  process  to  the  sternum  over  the  sternomastoid  muscle.  A  second 
incision  extended  from  the  left  mastoid  process,  around  the  angle  of  the 
jaw,  to  the  median  line  of  the  neck.   The  triangular  flap  was  reflected  and 


86  THE  BLOOD  CLOT 

the  anterior  fibres  of  the  sternomastoid  muscle  were  divided.  The  glands 
were  very  extensively  involved,  and  many  of  them  were  intimately  adherent 
to  the  tissues  surrounding  them.  Several  of  the  glands  were  ruptured  dur- 
ing the  operation  and  their  contents  spilled  into  the  wound.  The  internal 
jugular  vein  was  stripped  quite  bare  from  one  end  of  the  wound  to  the  other. 
The  wound  was  closed  with  a  continuous  suture. 

April  23d. — The  wound  is  healed  and  the  patient  discharged  from  the 
hospital. 

Example  2. — Excision  of  axillary  glands. — No.  69.  Mary  Green,  aet.  24, 
was  admitted  to  the  hospital  July  29,  1889.  For  seven  years  patient  has 
been  annoyed  with  tuberculous  cervical  glands.  These  glands  have  repeat- 
edly inflamed  and  "  burst."  At  present  the  patient's  neck  does  not  annoy 
her.  There  are  several  large  scars  in  the  neck  but  no  sinuses.  Four  or  five 
months  ago  the  glands  of  the  left  axilla  began  to  enlarge.  There  is  now  in 
the  left  axilla  a  painful  lump  about  as  large  as  a  lemon. 

Operation,  July  30,  1889. — The  axillary  glands  were  extirpated.  The 
wound  was  closed  in  the  usual  way  and  the  fornix  of  the  axilla  carefully 
held  up  with  gauze. 

August  6th. — The  wound  is  dressed.  It  has  healed  in  the  typical  way. 

Example  3. — Excision  of  inguinal  glands  and  of  a  tuberculous  ulcer  of 
the  foot. — No.  327.  Henry  S.  Young,  aet.  18,  was  admitted  to  the  hospital 
February  13,  1890.  Four  years  ago  the  patient  was  kicked  on  the  outer 
border  of  his  left  foot.  The  foot  swelled,  and  in  a  few  weeks  a  sore  was 
established  in  the  skin  over  the  fifth  metatarsal  bone.  After  remaining  open 
for  two  years,  the  sore  became  closed  for  three  or  four  weeks.  It  then  re- 
opened and  has  been  a  running  sore  ever  since.  Two  and  a  half  years  ago 
the  glands  in  the  left  inguinal  region  began  to  enlarge  and  in  a  short  time 
they  suppurated.  About  six  months  ago  one  or  two  glands  in  the  left  popli- 
teal space  inflamed  and  suppurated. 

Examination. — In  the  skin  over  the  upper  and  outer  surface  of  the  fifth 
metatarsal  bone  of  the  left  foot  is  a  sore  about  3.5  cm.  in  diameter  which 
presents  the  appearances  described  as  characterizing  what  used  to  be  known 
as  scrofuloderma.  The  granulations  are  subcutaneous  in  parts  of  the  sore. 
Over  the  subcutaneous  granulations  the  papillae  of  the  skin  are  enlarged 
and  covered  with  thick  crusts  of  epithelium.  The  edges  of  the  open  sore  are 
thin  and  red  and  irregularly  undermined.  The  base  of  the  open  sore  gives 
the  picture  of  the  tuberculous  ulcer  of  the  skin.  Here  and  there  the  granu- 
lations are  thinly  covered  with  epithelium. 

Operations,  February  15,  1890. — 1.  Quite  a  large  piece  of  tuberculous 
skin  was  removed  from  over  the  tuberculous  inguinal  glands.  The  glands 
were  carefully  excised.  The  wound  was  allowed  to  fill  with  blood:  it  was 
then  covered  with  gutta-percha  tissue  and  dressed  with  sterilized  gauze. 
2.  The  ulcer  of  the  foot  was  excised.  The  wound  was  protected  with  gutta- 
percha tissue  and  dressed  with  sterilized  gauze. 

February  23d. — The  wound  of  the  groin  is  dressed.  It  is  typically  healed. 
The  blood  clot  is  decolorized  at  its  centre  and  already  organized  at  its  edges. 

March  5th. — The  foot  wound  is  dressed.  The  blood  clot  is  completely 
replaced  by  granulation  tissue  which  is  rapidly  being  covered  with 
epithelium. 


THE  TREATMENT  OF  WOUNDS  87 

IV.  Operations  for  Carcinoma  of  the  Breast 

Thirteen  cases.  Nos.  58,  177,  216,  326,  360,  373,  381,  385,  388,  407,  408, 
454,  and  489.   Typical  healing  in  all  of  the  cases. 

Example. — No.  381.  Wealthy  Mason,  aet.  47,  was  admitted  to  the  hos- 
pital March  20,  1890. 

About  one  year  ago  the  patient  noticed  a  lump  no  larger  than  a  pea  just 
external  to  the  left  nipple.  The  lump  has  gradually  increased  in  size  and  is 
now  about  as  large  as  a  hen's  egg.  The  axillary  glands  are  large  enough  to 
be  felt. 

Operation,  March  21,  1S90. — The  knife  was  introduced  at  a  point  from 
3  cm.  to  5  cm.  below  the  middle  of  the  clavicle  and  drawn  outwards  on  to 
and  down  the  arm  to  a  point  a  little  below  the  insertion  of  the  pectoralis 
major  muscle.  The  knife  was  then  reintroduced  at  the  starting  point  and 
the  tumor  circumscribed  by  a  skin  incision  which  gave  the  diseased  tissues 
at  every  point  a  wide  berth — a  berth  of  at  least  5  cm.  Each  bleeding  point 
as  it  presented  itself  was  caught  at  once  by  an  artery  clamp.  The  tumor, 
the  entire  breast  and  all  of  the  healthy  tissues  which  had  been  circumscribed 
by  the  skin  incision  were  removed  in  one  piece  from  within  outwards,  by 
cutting  and  tearing,  from  the  ribs  and  from  the  fascia  which  covers  the 
greater  pectoral  muscle.  The  triangular  skin  flap  was  dissected  back  to  its 
base.  The  loose  fascia  which  stretches  from  the  lower  border  of  the  free 
edge  of  the  pectoralis  major  muscle  to  the  chest  wall  was  torn  through  with 
the  fingers,  the  major  muscle  was  raised  up  from  the  chest  wall  and  from 
the  pectoralis  minor  muscle  and  cut  away  close  to  its  trunk  attachments  and 
at  about  5  cm.  from  its  insertion  into  the  humerus.  The  pectoralis  minor 
muscle  was  divided  transversely  at  about  its  middle  and  drawn  upwards  so 
as  to  completely  expose  the  extreme  apex  of  the  axilla  under  the  clavicle. 
The  loose  cellular  tissue  about  the  first  portion  of  the  axillary  vein  was  dis- 
sected away  with  the  fingers  so  as  to  clearly  expose  the  axillary  vein.  Start- 
ing from  this  point  the  tissues  were  dissected  clean  from  the  axillary  vessels 
and  nerves,  down  almost  to  the  lower  limit  of  the  skin  incision  on  the  arm. 
Going  back  again  to  the  apex  of  the  axilla,  the  axillary  contents  and  with 
them  all  the  cellular  tissue  and  fat  which  covers  the  front  and  side  of  the 
exposed  chest  wall  were  dissected  off,  clean  from  the  ribs.  The  somewhat 
wedge-shaped  contents  of  the  axilla  were  thus  removed  in  one  piece  from 
the  apex  to  the  base  or  floor  of  the  axilla.  The  floor  of  the  axilla  had  already 
been  reflected  in  the  triangular  skin  flap.  The  last  cutting  act  of  the  opera- 
tion, therefore,  was  to  dissect  the  base  of  the  wedge-shaped  contents  of  the 
axilla  from  the  reflected  triangular  flap  of  skin. 

Two  strong  silk  approximation  sutures  were  taken  from  the  under  side 
of  the  skin  at  about  1.5  cm.  from  its  cut  margins.  These  sutures,  stretched 
across  the  open  wound,  did  not  touch  the  ribs  but  were  suspended  in  the 
air  about  midway  between  the  ribs  and  the  level  of  the  skin.  The  flap  was 
then  pressed  up  into  the  axilla  to  as  high  a  point  as  possible  and  was  held 
there  by  an  assistant  while  its  edges  were  stitched  with  buried  skin  sutures 
to  the  skin  of  the  chest  wall.  The  open  wound  was  allowed  to  fill  with  blood. 
The  approximation  sutures  became  completely  buried  in  the  blood  clot.  The 
blood  clot  was  protected  from  the  dressing  by  strips  of  gutta-percha  tissue. 


88  THE  BLOOD  CLOT 

The  fornix  of  the  axilla  was  made  as  high  as  possible  and  its  high  position 
was  maintained  by  a  wedge  of  gauze  which  was  held  in  place  by  a  firmly 
applied  bandage.  The  inner  dressing  was  of  sterilized  gauze  and  the  outer 
dressing  of  Cyprus  moss. 

April  7th. — The  wound  is  dressed.  It  has  healed  in  the  typical  way. 
The  blood  clot,  which  is  already  almost  completely  organized,  fills  the  open 
wound  up  to  the  level  of  the  skin.  The  approximation  sutures  are  buried 
out  of  sight  in  the  blood  clot.  The  positions  of  the  approximation  sutures 
are  indicated  by  little  convexities  of  the  skin  at  the  margins  of  the  blood 
clot :  vid.  Plate  III,  O,  O,  and  X ,  X .  A  little  above  the  centre  of  the  open 
wound  white  spots  may  be  seen  in  the  photograph,  and  at  the  lower  part  of 
the  open  wound  near  its  inner  edge  are  some  dark  spots.  The  white  spots 
represent  the  decolorized  remains  of  the  blood  clot,  and  the  dark  spots 
represent  the  most  deeply  pigmented  areas  of  the  blood  clot.  The  granula- 
tion tissue  had  reached  the  surface  everywhere  except  at  these  light  and 
dark  spots.  Sometimes  at  the  first  dressing  the  approximation  sutures  may 
be  seen  shimmering  through  the  surface  of  the  blood  clot.  They  soon  become 
entirely  concealed  by  the  granulation  tissue. 

About  eight  years  ago  [1882]  I  began  not  only  to  typically  clean  out  the 
axilla  in  all  cases  of  cancer  of  the  breast  but  also  to  excise  in  almost  every 
case  the  pectoralis  major  muscle,  or  at  least  a  generous  piece  of  it,  and  to 
give  the  tumor  on  all  sides  an  exceedingly  wide  berth.  It  is  impossible  to 
determine  with  the  naked  eye  whether  or  not  the  disease  has  extended  into 
the  pectoral  muscle. 

From  the  careful  microscopical  examination  of  many  very  small  cancers 
of  the  breast  I  am  convinced  that  the  pectoralis  major  muscle  is  usually  at 
the  time  of  the  operation  involved  in  the  new  growth.  Strange  to  say,  no 
authority  so  far  as  I  know  suggests  the  advisability  of  always  removing  the 
pectoralis  muscle  or  a  portion  of  it  in  operations  for  the  cure  of  cancer  of 
the  breast;  and  still  stranger  there  are  many  surgeons  of  the  first  rank — 
surgeons  in  favor  of  methodically  cleaning  out  the  axilla — who  instead  of 
recommending  the  excision  of  the  muscle  advise  the  removal  of  the  fascia 
only  from  the  pectoral  muscle.  Konig,"  for  example,  in  the  fourth  edition 
of  his  Surgery  says :  "  When  the  fascia  over  the  pectoralis  muscle  is  diseased 
it  (the  fascia)  must  be  removed."  Surely  it  is  absurd  not  to  remove  the 
muscle  when  its  fascia  is,  even  to  the  naked  eye,  diseased. 

Kiister  M  in  describing  his  method  says :  "  Now  the  breast  and  with  it 
the  fascia  pectoralis  is  detached  from  below  upwards."  He  adopts  Volk- 
mann's  technique  and  apparently  accepts  his  views  on  the  importance  of 
removing  the  pectoral  fascia. 

"  F.  Konig,  Lehrbuch  der  Speciellen  Chirurgie,  4  cd.,  vol.  ii,  p.  107. 
™  E.  Kiister,  Verhandlungen  d.  deutsch.  Ges.  f .  Chir.,  1883,  p.  295. 


THE  TREATMENT  OF  WOUNDS  89 

Volkmann  "  in  his  Beitrage  zur  Chirurgie  writes  as  follows : 
"  I  make  it  a  rule  never  to  do  a  partial  amputation  for  cancer  of  the 
breast,  but  remove  the  entire  breast  even  for  the  smallest  tumors,  and  at 
the  same  time  I  take  away  a  liberal  piece  of  skin.  The  skin  defect  is,  of 
course,  very  great  when  one  operates  in  this  manner,  and  the  wound,  in  con- 
sequence, requires  a  long  time  for  healing.  Furthermore,  in  making  the 
lower  incision  I  cut  right  down  to  the  pectoralis  muscle  and  clean  its  fibres 
as  I  would  for  a  classroom  dissection,  carrying  the  knife  parallel  with  the 
muscular  fasciculi  and  penetrating  into  their  interstices.  The  fascia  of  the 
muscle  is,  accordingly,  entirely  removed.  I  was  led  to  adopt  this  procedure 
because,  on  microscopic  examination,  I  repeatedly  found  when  I  had  not 
expected  it  that  the  fascia  was  already  carcinomatous,  whereas  the  muscle 
was  certainly  not  involved.  In  such  cases  a  thick  layer  of  apparently  healthy 
fat  separated  the  carcinoma  from  the  pectoral  muscle  and  yet  the  cancerous 
growth,  in  places  demonstrable  only  with  the  microscope,  had  shot  its  roots 
along  the  fibrous  septa  down  between  the  fat  lobules  and  had  reached  and 
spread  itself  out  in  flat  islands  in  the  fascia.  It  seems  to  me,  therefore,  that 
the  fascia  serves  for  a  time  as  a  barrier  and  is  able  to  bring  to  a  halt  the 
spreading  growth  of  the  carcinoma." 

V.  Operations  foe  the  Radical  Cure  of  Inguinal  Hernia  in  the  Male 

Eight  cases.15  Nos.  94,  171,  250,  329,  330,  460,  448,  and  481.  Typical 
healing  in  seven  of  the  cases.  In  one  case,  No.  94,  the  bladder  had  been 
included  in  one  or  more  of  the  sutures. 

Example  1. — No.  339.  Henry  Smith,  negro,  aet.  37,  was  admitted  to  the 
hospital  February  19,  1890.  For  two  years  the  patient  has  had  a  small  right 
oblique  inguinal  hernia.  At  present  the  hernia  is  about  as  large  as  an  orange 
and  is  easily  reducible. 

Operation" February  20, 1890. — The  skin  incision  extended  from  a  point 
about  2  cm.  internal  to  the  anterior  superior  spine  of  the  ilium  to  the  spine 
of  the  pubes;  vid.  Plate  IV.  The  subcutaneous  tissues  were  divided  so  as 
to  expose  clearly  the  aponeurosis  of  the  external  oblique  muscle,  the  external 
abdominal  ring  and  the  sac  of  the  hernia.  The  aponeurosis  of  the  external 
oblique  muscle,  the  internal  oblique  and  the  transversalis  muscles  and  the 
transversalis  fascia  were  severed  to  the  outer  extremity  of  the  skin  incision. 
An  incision  large  enough  to  admit  two  fingers  was  then  made  into  the  sac. 
The  index  and  middle  fingers  of  the  left  hand,  and  a  small  piece  of  sterilized 
gauze  were  passed  into  the  sac.  By  them  the  hernial  contents  were  pressed 
back  into  the  abdominal  cavity  and  over  the  fingers  the  sac,  first  on  one 
side  and  then  on  the  other,  was  drawn  tense  and  held  by  the  thumb  of  the 

14  R.  Volkmann,  Beitrage  zur  Chirurgie.    Leipzig,  1875,  p.  329. 

*  February  17,  1891.  I  have  performed  the  operation,  as  described  below,  for  the 
radical  cure  of  inguinal  hernia  twenty-one  times.  In  no  case,  in  so  far  as  I  have  been 
able  to  inform  myself,  has  the  hemia  returned.  Last  evening,  at  a  meeting  of  the 
Hospital  Medical  Society,  eleven  of  the  cases  presented  themselves  for  examination. 
In  one  case  only  I  did  not  transplant  the  cord ;  in  this  case  the  hernia  has  returned. 

"Vid.  The  Johns  Hopkins  Hospital  Bulletin,  1889,  vol.  i,  No.  1. 


M  THE  BLOOD  CLOT 

same  hand,  while  the  tissues  in  which  the  sac  was  imbedded  were  stripped 
off  from  it  by  the  other  hand.  With  the  division  of  the  abdominal  muscles 
and  transTersalis  fascia  the  so-called  neck  of  the  sac  vanishes.  There  is  no 
longer  a  constriction  of  the  sac.  The  communication  between  the  sac  and 
the  abdominal  cavity  is  more  than  large  enough  to  admit  one's  hand.  The 
sac  having  been  completely  isolated,  was  torn  more  widely  open,  and  the 
peritonaea!  cavity  was  closed  as  deeply  as  possible  by  seven  or  eight  quilted 
-  :  :  -  :  ".:  -  .-:..  7'...  -.  :  "  -  :":..-:  _  :  :■.-.."  -.:::.-.-.  ;".:-•.-  :;  :7r  line  ;:  :7e 
peritonaeal  sutures.  The  vas  deferens  and  its  vessels  having  been  isolated, 
they  were  hooked  up  into  the  outer  angle  of  the  wound  by  a  quilted  suture, 
which  included  the  transversalis  and  internal  oblique  muscles  and  the 
aponeurosis  of  the  external  oblique  muscle.  This  suture  was  the  first  of  a 
row  of  seven  or  eight  quilted  sutures  of  strong  silk,  which  were  passed  deeply 
through  the  pillars  of  the  ring,  and  through  the  divided  muscles  of  the 
abdominal  walL  These  sutures  were  taken  very  close  together,  were  made 
to  include  the  deepest  tissues  available  and  were  tied  tight  enough  to  bring 
into  close  apposition  the  broad  surfaces  which  they  embraced. 

Great  care  having  been  taken  to  ligate  every  bleeding  point,  the  wound 
was  closed  with  buried  skin  sutures  of  fine  black  silk.  A  rai  ::  ~:er7:zei 
gauze  about  3  cm.  broad  and  a  little  longer  than  the  wound  was  pressed 
over  the  line  of  the  skin  incision.  The  skin  of  the  abdomen,  thigh  and 
scrotum  was  carefully  dried.  The  pad  was  bound  firmly  in  position  by  a 
few  spica  turns  of  a  gauze  bandage  which  had  been  soaked  in  absolute 
alcohol.  Finally  thin  collodion  was  poured  over  the  entire  dressing.  In  a 
few  moments  the  dressing  was  quite  hard  and  the  patient  was  transferred  to 
the  stretcher. 

March  1st. — The  wound  is  dressed.  The  wound  is  perfectly  healed.  Noth- 
ing but  the  finest  linear  scar  is  to  be  seen ;  rid.  Plate  IV. 

March  6th. — Thirteen  days  *  after  the  operation  the  patient  is  allowed 
to  get  out  of  bed  and  to  walk  about 

November,  1890. — Nine  months  after  the  operation  the  scar  from  the 
operation  is  scarcely  visible.  There  is  no  return  of  the  hernia. 

Examfli      — S      "'4.   This  is  the  only  case  which  did  not  heal  in  the 
typical  way.  John  Bleecher,  aet-  48,  was  admitted  to  the  hospital  Aug-:  - 
1889.    Patient  has  an  oblique  inguinal  hernia  on  both  sides.    The  hernia 
on  the  right  side  is  the  larger  and  has  existed  for  about  fifteen  years.  It  has 
caused  him  so  much  pain  of  late  that  he  desires  to  be  cured  of  it  by  operation. 

Operation.  August  16,  1889. — The  operation  was  done  in  the  way  just 
described.  The  ring  was  large  enough  to  admit  four  fingers. 

August  20th. — Patient  has  not  been  able  since  the  operation  to  micturate 
without  great  difficulty.  It  is  only  by  getting  on  his  hands  and  knees  that 
he  has  been  able  to  do  so.  His  pulse  today  is  136.  and  his  temperature  is 
39.3°  C.  The  dressings  are  removed.  The  patient  is  anaesthetized,  and  the 
wound,  which  looks  as  if  it  were  healed,  is  cut  open.  There  escapes  from 
the  wound  a  considerable  amount  of  a  very  thin,  brownish,  somewhat  blood- 
stained fluid.  The  wound  is  left  open. 

K  The  patients,  as  a  rule,  are  not  allowed  to  walk  about  until  the  twenty-fint  day 
after  the  operation. 


THE  TKEATMENT  OF  WOUNDS  91 

August  24th. — Patient's  temperature  and  pulse  are  still  a  little  above 
normal.  His  dressings  were  found  soaked  with  urine  this  morning.  The 
urine  certainly  reaches  the  dressings  by  way  of  the  wound,  and  hence  it  is 
probable  that  the  wall  of  the  bladder  was  caught  by  one  or  more  of  the  deep 
sutures. 

September  8th. — Three  days  ago  the  patient  voided  some  of  his  urine  in 
the  natural  way,  but  until  today  the  greater  part  of  the  patient's  urine  has 
escaped  through  the  wound. 

September  10th. — There  has  been  no  urine  on  the  dressings  since  the  last 
note. 

November,  1890. — The  patient  made  a  perfect  recovery,  and  up  to  date, 
15  months  after  the  operation,  has  had  no  return  of  his  hernia. 

VI.  Amputations  of  the  Thigh 
Two  cases.  Nos.  313  and  364.  Typical  healing  in  both  cases. 

Example. — Amputation  of  the  thigh  at  the  lower  part  of  its  upper  third 
for  sarcoma  of  the  knee-joint. — No.  313.  W.  B.  Griffen,  aet.  22. 

Operation,  April  26, 1890. — Neither  the  tourniquet  nor  the  Esmarch  ban- 
dage was  made  use  of.  The  vessels  were  tied  as  they  were  encountered  and 
before  they  were  divided.  The  patient  did  not  lose  more  than  one  or  two 
ounces  of  blood.  The  patient  was  in  a  bad  condition  for  the  operation.  But 
the  loss  of  blood  was  so  little  that  his  pulse  was  about  as  strong  after  the 
operation  as  it  was  before  it.  A  circular  and  two  lateral  incisions  were  made 
through  the  skin.  The  rectangular  flaps  were  dissected  back  about  6  cm. 
The  vessels  were  divided  separately.  The  muscles  and  skin  flaps  were  inten- 
tionally made  quite  short.  Long  flaps  are  of  course  unnecessary  when  a 
wound  unites  by  first  intention.  The  muscles  were  brought  together  quite 
loosely  by  fine  silk  buried  sutures.  No  attempt  was  made  to  obliterate  the 
rather  large  dead  space  between  the  sawed  end  of  the  bone  and  the  muscles. 
The  danger  of  strangulating  tissue  in  the  effort  to  obliterate  this  dead  space 
is  so  great  that  I  prefer  to  allow  a  blood  clot  to  occupy  it.  The  smaller  dead 
spaces  were  ignored.  The  skin  flaps  were  trimmed  short  and  their  edges 
were  brought  together  gently  by  buried  skin  sutures  of  fine  silk.  These 
sutures  were  placed  about  3.5  cm.  apart.  Abundant  opportunity  was  thus 
afforded  for  the  escape  of  blood.  The  skin  wound  was  covered  with  gutta- 
percha tissue.  The  dressing  was  of  sterilized  gauze.  The  stump  was  flexed 
at  right  angles  to  the  trunk  and  held  in  place  by  a  plaster  of  Paris  bandage. 

May  5th. — Nine  days  after  the  operation,  the  dressing  was  removed  at  a 
meeting  of  The  Johns  Hopkins  Hospital  Medical  Society.  The  wound  had 
healed  throughout  by  first  intention. 

VII.  Aetheodesis  foe  Paealttic  Flail-Joint 

Five  cases.  Nos.  178,  322,  348,  416,  444.  Typical  healing  in  all  of  the 
cases. 

Example. — No.  348.  Mollie  Morris,  aet.  17,  was  admitted  to  the  hospital 
February  26,  1890.  She  had  an  attack  of  infantile  paralysis  when  she  was 
two  years  old.  Her  right  ankle  is  now  a  flail-joint.  She  brings  her  foot  to 
the  ground  in  an  extreme  valgus  position.    Her  foot  pains  her  almost  con- 


92  THE  BLOOD  CLOT 

tinuously  whether  she  uses  it  or  not.  The  pain  is  very  great  when  she 
attempts  to  walk. 

Operation. — The  joint  was  opened  by  an  anterior  traDSverse  incision. 
Everything  encountered  except  the  anterior  tibial  vessels  and  nerve  was 
divided.  The  articular  surfaces  and  with  them  thin  discs  of  the  tibia,  fibula 
and  astragalus  were  removed.  The  tibia  and  astragalus  were  held  together 
by  strong  silk  sutures.  The  skin  wound  was  united  by  buried  skin  sutures, 
covered  with  gutta-percha  tissue  and  dressed  with  sterilized  gauze. 

March  1st. — The  dressing  is  removed  in  order  that  a  close  fitting  plaster 
of  Paris  splint  may  be  applied.  The  wound  is  perfectly  healed. 

April  Jfth. — The  plaster  splint  is  removed.  There  is  firm  union  between 
the  tibia  and  the  astragalus. 

October,  1890. — The  position  of  the  foot  is  still  good  and  the  patient 
walks  well  and  without  pain. 

VIII.  Trendelenberg-Hahn   Operation  for  the  Cure  of  Acquired 

Flat  Foot 

Two  cases.   Nos.  334  and  466.  Typical  healing  in  both  cases. 

Example. — No.  466.  Charles  Brown,  aet.  15,  was  admitted  to  the  hospital 
May  20,  1890.  About  one  year  ago  patient's  left  foot  began  suddenly  to  give 
him  pain  when  he  walked.  The  foot  became  swollen,  and  when  the  swelling 
had  disappeared  the  patient  noticed  that  one  of  the  "  ankle  bones  "  was 
projecting. 

Examination. — The  patient's  foot  pronates  when  he  walks.  He  walks 
upon  the  inner  side  of  his  foot.   He  has  a  typical  flat  foot. 

Operation,  May  21,  1890. — The  tibia  was  chiseled  through  a  little  above 
the  ankle  joint  as  advised  by  Trendelenberg  and  Hahn.  As  it  was  still  im- 
possible to  bring  the  foot  into  a  strong  varus  position,  a  wedge-shaped  piece 
of  bone  was  removed  from  the  tibia.  Without  much  force  the  foot  could 
then  be  brought  into  a  satisfactory  position.  The  skin  wound  was  stitched 
with  buried  skin  sutures,  covered  with  gutta-percha  tissue  and  dressed  with 
sterilized  gauze.  The  varus  position  was  maintained  by  a  plaster  of  Paris 
splint. 

June  1,  1890. — The  wound  is  dressed.  It  has  healed  primarily.  A  close 
fitting  plaster  of  Paris  splint  is  applied. 

IX.  Operations  for  Ununited  Fractures 

Two  cases.   Typical  healing  in  both  cases. 

Humerus:   1  case.   No.  419.   Femur:   1  case.   No.  449. 

Example. — No.  449.  I.  A.  Dorsey,  aet.  54,  was  admitted  to  the  hospital 
May  2,  1890.  In  October,  1889,  the  patient  sustained  a  simple  fracture  of 
the  right  femur.  He  was  treated  for  seven  weeks  with  a  Smith's  anterior 
splint,  and  has  not  been  able  to  walk  since  the  accident. 

Examination. — The  right  thigh  is  7.5  cm.  shorter  than  the  left.  There 
is  an  ununited  fracture  of  the  right  femur  at  a  point  a  little  above  its  middle. 
The  upper  fragment  is  abducted  and  rotated  outwards.  Its  lower  end  is 
sharp  and  pointed,  and  1ms  almost  perforated  the  skin. 


THE  TREATMENT  OF  WOUNDS  93 

Operation,  May  7,  1890. — The  inflamed  skin  over  the  lower  end  of  the 
upper  fragment  was  excised.  A  longitudinal  incision,  about  15  cm.  long, 
was  made  on  the  outer  side  of  the  thigh.  From  the  middle  of  this  incision 
and  at  right  angles  to  it  a  transverse  incision,  about  5  cm.  long,  was  carried 
towards  the  back  of  the  thigh.  The  ends  of  the  fragments  were  so  greatly 
atrophied  and  overlapped  so  much,  that  it  was  thought  advisable  to  remove 
4  cm.  from  the  upper  and  3  cm.  from  the  lower  fragment.  The  bones  were 
drilled  and  fastened  together  by  strong  silk.  The  skin  wound  was  stitched 
with  buried  skin  sutures  and  covered  with  gutta-percha  tissue. 

No  attempt  was  made  to  obliterate  by  buried  sutures  the  dead  spaces  of 
the  wound.  The  dressings  were  of  sterilized  gauze  and  Cyprus  moss.  The 
thigh  was  immobilized  in  a  plaster  of  Paris  splint. 

May  31st. — The  wound  is  examined.  It  has  healed  primarily.  There  is 
as  yet  no  evidence  of  bony  union. 

X.  Operations  for  Fractures  of  the  Patella 
Two  cases.  Nos.  247,  362.  Typical  healing  in  both  cases. 

Example. — No.  247.  Robert  Sommering,  aet.  41,  was  admitted  to  the 
hospital  December  10,  1889.  A  few  hours  before  admission  the  patient 
tripped  over  a  car  track,  and  in  falling  "  felt  both  knee  caps  break  "  before 
they  touched  the  ground. 

December  11th. — The  right  knee  was  put  up  in  an  apparatus  by 
Dr.  Brockway,  the  house  surgeon. 

Operation,  December  18th. — A  transverse  incision  was  made  into  the 
left  knee-joint  between  the  fragments.  The  upper  fragment  did  not  com- 
prise quite  the  whole  of  the  upper  third  of  the  patella.  This  fragment  was 
tilted  in  such  a  manner  that  its  fractured  surface  looked  almost  directly 
upwards  as  the  patient  lay  upon  his  back.  All  the  tissues  from  the  skin 
down  to  the  bone  had  slipped  in  between  the  fragments;  so  that  to  bring 
the  fragments  accurately  together  without  an  operation  would  have  been 
impossible.  The  tissues  interposed  between  the  broken  surfaces  were  cut 
away  and  the  fragments  were  accurately  brought  together  by  sutures  which 
did  not  pass  through  the  bone.  The  skin  wound  was  united  by  buried  skin 
sutures,  covered  by  gutta-percha  tissue  and  dressed  with  sterilized  gauze. 

December  17th. — The  wound  is  dressed.  It  has  healed  primarily.  The 
left  leg  is  put  up  in  a  plaster  of  Paris  splint.  Between  the  fragments  of  the 
unsutured  patella  is  a  gap  of  about  1.5  cm. 

June,  1890. — Patient  has  had  another  fall  and  has  torn  the  ligamentous 
union  which  existed  between  the  fragments  of  the  patella  which  was  not 
sutured.  He  has  already  almost  perfect  motion  of  the  left  knee.  The  left 
patella  is  apparently  perfect.  A  few  days  after  the  readmission  of  the  patient, 
Dr.  Brockway,  the  house  surgeon,  sutured  the  fragments  of  the  right  patella. 

XI.  Osteotomy  for  Bow-Legs 

Three  cases.  Nos.  236,  336,  410.   Typical  healing  in  all  of  the  cases. 

Example. — No.  410.  Richard  Schmidt,  aet.  7,  was  admitted  to  the  hos- 
pital April  9,  1890.  His  parents  state  that  his  legs  began  to  bend  when  he 


94  THE  BLOOD  CLOT 

was  two  years  old.  The  bowing  has  increased  steadily  from  that  time  to 
this.  The  boy  has  now  well  marked  anterior  curvature  and  very  exaggerated 
lateral  curvature  of  both  legs. 

Operation,  April  10,  1S90. — Both  legs  were  operated  upon.  Transverse 
skin  incisions  were  made  opposite  the  apices  of  the  lateral  curves.  The 
tibiae  were  divided  with  the  osteotome.  The  fibulae  were  broken  by  hand. 
The  skin  wounds  were  united  by  buried  skin  sutures,  covered  with  gutta- 
percha tissue  and  dressed  with  gauze.  The  legs  were  immobilized  in  plaster 
of  Paris  dressings. 

April  27th. — The  dressings  are  removed.  The  wounds  are  perfectly 
healed.  There  is  already  considerable  bony  union  of  both  tibiae.  The  slight 
deformity  which  still  remains  is  corrected  and  the  legs  reencased  in  plaster 
of  Paris. 

May  22d. — Patient's  legs  are  firm  and  quite  straight.  He  is  allowed  to 
walk. 

XII.  INCISION  AND  IRRIGATION   OF  JOINTS   FOR  GONORRHOEAE  ARTHRITIS 

Three  cases.  No.  77,  knee;  No.  104,  ankle;  No.  172,  wrist.  Typical  heal- 
ing in  all  of  the  cases. 

Example. — No.  77.  John  Schlenck,  aet.  57.  Admitted  to  hospital 
August  2,  1889.  Patient  has  gonorrhoea.  His  right  knee  and  left  ankle 
joints  are  distended  with  fluid  and  are  very  painful.  There  is  considerable 
oedema  of  the  right  leg  and  of  the  left  foot. 

Operation,  August  3,  1S89. — An  incision  about  10  cm.  long  was  made 
along  the  inner  edge  of  the  patella  and  into  the  joint.  The  joint  was  dis- 
tended with  a  blood-stained,  sero-purulent  exudate.  The  fluid  was  evacu- 
ated and  the  joint  irrigated  for  twenty  minutes  with  a  solution  of  corrosive 
sublimate  (1-50,000).  Two  or  three  interrupted  silk  stitches  were  taken 
in  the  capsule  of  the  joint.  The  muscle  wound  was  not  sutured.  The  skin 
wound  was  stitched  with  buried  sutures  of  fine  silk  and  covered  with  gutta- 
percha tissue.  The  knee  was  dressed  with  sterilized  gauze  and  fixed  in  an 
extended  position. 

August  lJfth. — The  dressings  are  removed.  The  wound  is  healed.  There 
is  no  fluid  in  the  joint,  but  flexion  of  the  joint  is  quite  painful. 

September  20th. — The  patient  can  flex  his  knee  joint  perfectly  and  with- 
out pain.  We  have  made  several  attempts  to  cultivate  on  human  blood 
serum  the  gonococcus  from  the  exudate  of  gonorrhoeal  joints,  but  without 
success.  In  one  instance  we  found,  beyond  a  doubt,  the  gonococcus  in  the 
fluid  from  a  knee  joint.  In  every  case  we  have  made  the  usual  test  tube 
inoculations  for  pyogenic  microorganisms  and  in  no  case  did  a  single  colony 
develop. 

XIII.  Extirpation  of  Inguinal  Glands  for  Gonorrhoeal  Adenitis 

Six  cases.  Nos.  344,  358,  392,  397,  432.  Typical  healing  in  five  of  the 
cases. 

In  the  unsuccessful  case,  No.  344,  the  original  dressing  was  removed  a 
few  days  after  the  operation  at  a  meeting  of  the  Hospital  Medical  Society. 


THE  TREATMENT  OF  WOUNDS  95 

The  wound  had  healed  primarily  but  the  blood  clot  did  not  completely  fill 
the  uncovered  dead  space  over  the  saphenous  opening.  The  wound  had 
probably  been  investigated  by  the  fingers  of  members  of  the  society  and 
hastily  redressed.  At  the  second  dressing  the  blood  clot  was  found  to  have 
broken  down  and  there  was  pus  at  the  bottom  of  the  dead  space. 

Example. — Double  inguinal  bubo. — No.  358.   John  B ,  aet.  20,  was 

admitted  to  the  hospital  March  5,  1890.  The  skin  over  the  glands  of  the 
right  groin  is  not  inflamed.  An  incision  had  already  been  made  into  the 
glands  of  the  left  groin. 

Operation,  March  6,  1890. — An  elliptical  piece  of  skin  which  included 
the  old  incision  was  removed  from  over  the  glands  of  the  left  groin.  Irregu- 
lar T-shaped  incisions  were  made  in  both  groins  and  the  glands  thoroughly 
extirpated  on  both  sides.  Several  of  the  softened  glands  burst  during  the 
operation  and  evacuated  their  contents  into  the  wounds.  It  seemed  advis- 
able, therefore,  to  irrigate  both  wounds  for  several  minutes  with  a  solution 
of  corrosive  sublimate,  1-1000.  The  wounds  were  sewed  with  buried  skin 
sutures.  At  the  bottom  of  each  wound,  over  the  saphenous  opening,  was  a 
rather  large  dead  space.  On  the  left  side  the  dead  space  could  not  be  covered 
by  skin.  These  spaces  were  allowed  to  fill  with  blood.  The  wounds  were 
covered  with  gutta-percha  tissue  and  dressed  with  gauze. 

March  IJfth. — The  wounds  are  redressed.  Both  wounds  have  healed  pri- 
marily. There  is  a  small  granulating  wound  on  the  left  side  which  repre- 
sents the  organized  blood  clot. 

XIV.  Operations  for  Syphilis  of  Boxes 
Two  cases.  Nos.  67  and  451.  Typical  healing  in  both  cases. 

Example  1. — Operation  for  gumma  of  the  external  condyle  of  the 
humerus. — No.  67.  Ida  Carson,  aet.  9,  negress.  Admitted  to  the  hospital 
July  29,  1889.  Patient  has  hereditary  syphilis.  Her  corneae  are  opaque,  her 
teeth  are  serrated.  The  external  condyle  of  the  left  humerus  is  enlarged 
and  sensitive  to  pressure. 

Operation,  August  1,  18S9. — The  external  condyle  was  freely  exposed  by 
a  long  longitudinal  incision  and  explored  with  the  chisel.  The  surface  of 
the  exposed  bone  was  rough  and  had  a  worm-eaten  look.  At  about  1  cm. 
from  the  surface  was  a  mass  of  necrotic  tissue  about  the  size  of  a  large 
filbert.  This  tissue  was  removed  and  the  walls  of  the  cavity  were  shaved 
with  a  sharp  spoon.  The  bone  cavity  was  allowed  to  fill  with  a  blood  clot. 
The  skin  was  loosely  stitched  with  buried  silk  sutures.  The  skin  wound 
was  covered  with  gutta-percha  tissue.  The  hand,  forearm  and  arm  were 
enveloped  in  a  sterilized  gauze  dressing.  The  elbow  was  fixed  in  an  ex- 
tended position  by  a  plaster  of  Paris  bandage. 

September  10th. — Forty-one  days  after  the  operation,  the  dressing  is 
removed  for  the  first  time.  The  wound  is  completely  healed.  There  is  per- 
fect motion  of  the  elbow  joint.  Before  the  operation,  the  elbow  could  not 
be  completely  extended. 

Example  2. — Operation  for  syphilitic  periostitis  of  a  rib. — No.  451. 
Moses  Conway,  aet.  23,  negro.    Admitted  to  the  hospital  May  5,  1890. 


96  THE  BLOOD  CLOT 

Patient  has  gummata  of  the  skull,  lower  jaw  and  rib.  About  5  cm.  below 
and  1  cm.  external  to  the  left  nipple  is  a  small  fluctuating  tumor.  The  long 
diameter  of  the  swelling  is  parallel  to  that  of  the  ribs  in  this  situation. 

Operation,  May  7,  1S90. — An  incision,  about  10  cm.  long,  was  made  into 
the  tumor.  Its  soft  necrotic  contents  were  evacuated  and  a  rib,  eroded  and 
deprived  of  its  periosteum,  was  exposed.  The  eroded  portion  was  removed, 
the  walls  of  the  cavity  excised  and  the  wound  irrigated  with  a  solution  of 
corrosive  sublimate,  1-1000.  The  wound  was  loosely  closed  with  buried 
skin  sutures  of  fine  silk,  covered  with  gutta-percha  tissue  and  dressed  with 
sterilized  gauze. 

May  10th. — The  wound  is  dressed.  It  has  healed  primarily. 

XV.  Xeceotomles  axd  Opebatioxs  toe  Boxe  Abscesses 

Eleven  cases.  Complete  organization  of  the  blood  clot  and  typical  healing 
in  eight  cases:  Xos.  142,  214,  325,  335,  366,  423,  430,  and  437.  Incom- 
plete organization  of  the  blood  clot  in  two  cases :  Xos.  340  and  352.  Com- 
plete disintegration  of  the  blood  clot  in  one  case:   Xo.  265. 

Example  1. — Sequestrotomy  for  osteomyelitis  of  the  tibia. — Xo.  437. 
Eichard  Kelly,  aet.  20,  was  admitted  to  the  hospital  April  19,  1890.  Patient 
had  an  acute  osteomyelitis  of  his  right  humerus  when  he  was  three  years 
old,  and  of  his  right  tibia  when  he  was  five  years  old.  Both  bones  have  been 
operated  upon  repeatedly.  The  sinuses  of  the  arm  and  leg  have  healed,  but 
there  is  now  a  large  abscess  over  the  middle  of  the  tibia.  The  skin  over  this 
abscess  is  inflamed  and  very  thin. 

Operation,  April  23,  1S90. — A  longitudinal  incision  about  18  cm.  long 
was  made  over  the  tibia.  The  front  wall  of  the  involucrum  was  chiseled 
away.  The  remains  of  the  sequestrum  were  removed,  and  the  granulations 
lining  the  involucrum  were  most  carefully  scraped  away.  The  bone  cavity 
was  thoroughly  painted  with  pure  carbolic  acid.  The  soft  walls  of  the 
abscess  were  excised  and  the  entire  wound  was  freely  washed  with  a  cor- 
rosive sublimate  solution,  1-1000,  and  then  with  a  carbolic  acid  solution, 
1-20.  The  wound  was  incompletely  closed  by  a  few  buried  sutures.  It  was 
then  allowed  to  fill  with  blood  and  was  covered  with  strips  of  gutta-percha 
tissue.  Moist  corrosive  sublimate  gauze  was  applied  next  to  the  gutta-percha 
tissue,  and  over  all  a  huge  dressing  of  sterilized  gauze.  The  knee  and  ankle- 
joints  were  immobilized  by  a  plaster  of  Paris  splint. 

May  oth. — The  dressing  is  removed  before  the  Hospital  Medical  Society. 
The  blood  clot  is  organized  throughout  and  the  wound  is  reduced  to  a  small 
granulating  sore. 

Example  2. — Sequestrotomy  for  osteomyelitis  of  the  humerus. — Xo.  423. 
Hermann  Wunderloh,  aet.  13,  was  admitted  to  the  hospital  April  15,  1890. 
About  one  year  ago  the  patient's  left  humerus  was  attacked  with  acute 
osteomyelitis.  About  one  week  after  the  onset  of  the  attack  an  abscess  ap- 
peared on  the  antero-internal  surface  of  the  upper  part  of  his  left  arm  and 
was  lanced  by  the  attending  physician.  Since  then  several  abscesses  have 
formed  about  the  humerus.  From  all  of  these  abscesses  pieces  of  bone  have 
from  time  to  time  been  discharged.   With  the  exception  of  one  sinus  at  the 


THE  TREATMENT  OF  WOUXDS  97 

upper  part  of  the  antero-internal  surface  of  the  arm  all  the  sinuses  are  now 
closed. 

Operation,  April  17,  1890. — An  incision  about  22  cm.  long  was  made 
from  one  end  of  the  humerus  to  the  other  over  its  antero-internal  surface. 
The  front  wall  of  the  inTolucrum  was  freely  chiseled  away  and  two  sequestra 
removed — one  from  near  the  upper  and  one  from  near  the  lower  end  of  the 
humerus.  The  granulations  lining  the  involucrum  were  carefully  scraped 
away.  The  gutter-shaped  cavity  was  thoroughly  cauterized  with  pure  car- 
bolic acid.  The  wound  was  irrigated  freely  with  a  corrosive  sublimate  solu- 
tion, 1-1000,  and  then  with  a  carbolic  acid  solution,  1-20.  The  skin  wound 
was  loosely  closed  by  buried  skin  sutures,  allowed  to  fill  with  blood,  covered 
with  gutta-percha  tissue  and  dressed  with  gauze. 

May  5th. — The  dressing  is  removed  before  the  Hospital  Medical  Society. 
The  wound  is  perfectly  healed. 

The  cases  in  which  there  was  partial  or  complete  disintegration  of  the 
blood  clot — cases  340,  352  and  265 — were  particularly  instructive  ones  to 
us.  In  case  340,  the  wound  was  completely  filled  with  granulation  tissue 
on  the  thirtieth  day  after  the  operation;  in  case  352,  on  the  fifteenth  day, 
and  in  case  265,  on  the  twenty -sixth  day. 

The  rapid  filling  of  these  large  bone  cavities,  notwithstanding  the  fact 
that  their  blood  clots  had  become  disintegrated  is,  I  think,  to  be  ascribed 
to  the  treatment  of  the  wounds.  The  slow  filling  of  such  cavities,  when 
treated  by  the  usual  methods,  must  likewise  be  ascribed  to  the  treatment. 
For  such  wounds  are  usually  stuffed  with  gauze.  In  ten  days  or  two  weeks, 
the  stuffing  is  removed,  and  with  it  the  granulations  which  have  grown 
into  it.  Then  the  wound  is  restuffed.  In  a  few  days  the  stuffing  is  again 
pulled  out  and  the  young  granulations  are  again  demolished.  This  treat- 
ment is  often  continued  for  months,  and  under  it  the  granulation  tissue 
becomes  converted  into  dense  fibrous  tissue,  poorly  supplied  with  blood  ves- 
sels and  unable  to  produce  anything  but  the  feeblest  granulations  which 
finally  become  more  or  less  completely  covered  with  epithelium.  And  so  it 
happens  that  these  large  bone  cavities  frequently  do  not  become  filled  and 
do  not  heal  and  remain  a  ghastly  reproach  to  the  surgeon. 

A  bone  cavity  should  never  be  stuffed.  The  granulations  should  be  en- 
couraged to  grow  as  luxuriantly  as  possible.  Whether  the  blood  clot  melts 
away  or  not,  the  bone  cavity  should  be  bridged  over  by  skin  or  by  protective 
or  gutta-percha  tissue.  The  granulations  must  be  most  carefully  protected 
from  insult.  They  should  rarely  if  ever  be  irrigated.  In  other  words,  a 
bone  cavity  which  has  lost  its  blood  clot,  should  be  treated  as  if  it  still  pos- 
sessed it.  If,  after  a  few  weeks,  the  cavity  is  not  filling  rapidly  it  should 
be  cauterized  with  pure  carbolic  acid,  its  granulations  should  be  made  to 
bleed  sufficiently  to  fill  the  cavity  with  blood  and  the  wound  should  be  given 
the  opportunity  to  heal  under  the  secondary  blood  clot.  Suppurating  wounds 


98  THE  BLOOD  CLOT 

of  soft  parts  should  be  treated  in  the  same  way.  They  should  not  be  stuffed. 
The  granulations  of  open  sores  should  be  protected  from  the  dressing  by 
gutta-percha  tissue  or  something  of  this  sort.  In  the  out-patient  depart- 
ment of  the  hospital  opportunities  are  afforded  us  nearly  every  day  to 
observe  the  astonishingly  rapid  healing  of  wounds  which  are  treated  in  this 
way.  For  example,  a  patient  with  scalp  wounds  two  or  three  weeks  old 
presents  himself.  There  is  considerable  oedema  of  the  scalp  and  the  wounds 
which  are  inflamed  are  found  stuffed  with  iodoformized  gauze.  We  remove 
the  stuffing,  cauterize  the  wounds  thoroughly  with  pure  carbolic  acid,  bridge 
them  over  with  gutta-percha  tissue  and  put  on  a  gauze  dressing  thick  enough 
to  protect  them.  If  we  examine  the  wounds  within  24  hours,  we  find  that  they 
are  filled  with  a  more  or  less  clear  and  solidified  wound  secretion.  Within 
72  hours  and  perhaps  within  48  hours,  the  "  secretion  clot,"  so-called  by  us, 
is  completely  organized  and  the  inflammation  and  oedema  of  the  scalp  have 
disappeared. 

Example  3. — From  the  wards.  A  boy  was  operated  upon  by  some  one  for 
an  ununited  fracture  of  the  bones  of  the  leg.     The  wound  suppurated. 

About  two  months  after  the  operation  the  boy  was  consigned  to  us  with 
a  wound  that  was  suppurating  freely  and  which  was  stuffed  with  iodoform- 
ized gauze.  We  made  two  longitudinal  incisions  into  the  wound,  removed 
the  wire  sutures,  scraped  away  with  the  utmost  care  the  granulation  tissue 
which  lined  the  suppurating  wound  and  sawed  off  a  thin  piece  of  bone  from 
each  of  the  fragments.  The  wound  was  then  cauterized  with  pure  carbolic 
acid  and  loosely  closed  by  buried  skin  sutures.  In  a  few  days  the  wound 
was  healed. 

XVI.  Extirpation  of  Vabicose  Veins  of  the  Leg  and  Thigh 
Four  cases.   Nos.  262,  279,  296  and  328.   Typical  healing  in  all  of  the 


Example. — No.  254.  Charles  H.  Gaupner,  aet.  48  years,  has  for  about 
twenty  years  been  annoyed  by  varicose  veins  of  both  thighs  and  legs.  On 
admission,  January  2,  1890,  patient  states  that  the  pains  in  his  legs  are 
severe  enough  to  incapacitate  him  from  work. 

Examination. — The  long  and  short  saphenous  veins  and  their  tributaries 
are  dilated,  thickened  and  very  tortuous.  There  is  oedema  of  the  left  leg. 

Operation  on  the  veins  of  the  left  leg,  January  10th. — An  incision  about 
60  cm.  long  was  made  over  the  internal  saphenous  vein — the  incision  ex- 
tended from  about  the  junction  of  the  lower  and  middle  thirds  of  the  thigh 
to  the  internal  malleolus.  The  veins  were  in  places  (back  of  the  internal 
condyle  of  the  femur  and  behind  the  malleolus)  adherent  to  the  skin.  This 
necessitated  the  making  of  skin  flaps  from  the  under-surface  of  which  the 
veins  were  cut  away.  The  internal  saphenous  vein  was  excised  from  one 
end  of  the  incision  to  the  other.  The  skin  was  stripped  back  for  about  two 
inches  on  both  sides  of  the  incision  and  the  underlying  veins  were  dissected 


THE  TREATMENT  OF  WOUNDS  99 

out.  The  wound  was  closed  with  a  continuous  suture  of  fine  black  silk.  No 
attempt  was  made  to  obliterate  the  dead  spaces.  The  line  of  suture  was 
covered  with  strips  of  gutta-percha  tissue.  The  dressings  were  of  sterilized 
gauze.  These  were  not  applied  tight  enough  to  interfere  with  the  circulation 
in  the  skin,  the  vitality  of  which  is  impaired  in  operations  for  the  removal 
of  varicose  veins:  the  dead  spaces  were,  consequently,  allowed  to  fill  with 
blood. 

January  17  th. — The  wound  is  dressed.  There  is  primary  union  through- 
out.  The  little  flap  behind  the  knee  has  sloughed  at  its  edge. 

January  30th. — The  little  slough  has  become  organized.  Its  place  is  occu- 
pied by  granulation  tissue.  The  patient  has  had  no  pain  since  the  operation. 

XVII.  Opekations  for  the  Removal  of  Cysts  and  New  Growths 

Fourteen  cases.  Nos.  82,  217,  238,  320,  354,  376,  382,  431,  433,  440,  442, 
446,  471,  and  491.  Typical  healing  in  all  of  the  cases. 

Example  1. — Osteoma  of  the  scapula. — No.  440.  Mildred  Calstron, 
aet.  18,  was  admitted  to  the  hospital  April  29,  1890. 

Operation,  April  30,  1890. — The  tumor,  about  the  size  of  a  hen's  egg, 
was  removed  from  the  infraspinous  fossa  near  the  axillary  border  of  the 
scapula.  The  wound  was  loosely  closed  with  buried  sutures  and  the  dead 
space  allowed  to  fill  with  blood.  The  dead  space  was  undoubtedly  consider- 
ably obliterated  by  the  pressure  of  the  dressing. 

May  6th. — The  wound  is  dressed.  It  has  healed  primarily. 

Example  2. — Syphilitic  testicle. — No.  446.  John  H.,  aet.  31,  was  ad- 
mitted to  the  hospital  May  1,  1890. 

Operation,  May  3,  1890. — Amputation  of  the  testicle.  The  wound  was 
closed  with  buried  sutures. 

May  8th. — The  wound  is  dressed.   It  has  healed  primarily. 

Example  3. — Lipoma  of  the  wall  of  the  thorax. — No.  369.  Martha 
Moore,  aet.  40. 

Operation,  March  13,  1890. — Removed  a  flat,  round  lipoma  about  9  cm. 
in  diameter  from  the  wall  of  the  thorax.  The  tumor  which  was  situated 
below  the  left  breast  on  the  prolongation  of  the  anterior  axillary  line  was 
bisected,  and  each  half  removed  from  within  outwards.  I  believe  this  to  be 
the  easiest  way  to  remove  lipomata,  cysts  and  other  benign  tumors.  The 
wound  was  closed  with  buried  skin  sutures,  covered  with  gutta-percha  tissue 
and  dressed  with  sterilized  gauze. 

March  19th. — The  dressing  is  removed.  The  wound  is  typically  healed. 
There  is  a  very  small  decolorized  blood  clot  at  the  inner  angle  of  the  wound. 

All  of  the  eleven  cases  of  group  XV  were  actively  suppurating  ones  at 
the  time  of  operation.  In  eight  of  these  cases  there  was  complete  and 
typical  organization  of  the  blood  clot;  in  two  of  them  the  organization  of 
the  blood  clot  was  incomplete,  and  in  one  case  there  was  complete  disinte- 
gration of  the  blood  clot. 


JvfV  OF  MA/7}^v 

100         J  THE  BLOOD  CLOT 

If  we  exclude  the  eases  of  this  group  there  remain  111  eases,  108  of  which 
healed  in  the  typical  way.  There  was  suppuration  in  two  cases  and  haemor- 
rhage in  one  case;  viol,  group  I.  From  October,  1889,  to  June,  1890,  all 
of  the  cases  healed  in  the  typical  way. 

Of  the  wounds  which  heal  primarily  probably  the  majority  do  so,  not- 
withstanding the  presence  of  microorganisms.  Success  in  the  treatment  of 
wounds  does  not  depend  alone  upon  the  exclusion  of  pyogenic  microorgan- 
isms from  the  wounds  for  the  following  reasons : 

1.  There  is  not,  I  believe,  a  technique  which  from  a  bacteriological  point 
of  view  may  be  considered  perfect. 

2.  Test  tube  inoculations  made  by  us  a  few  days  after  the  operations 
from  the  surface  of  the  new  cicatrix,  from  the  fine  line  of  granulations, 
from  the  surface  of  the  blood  clot,  from  the  tip  of  the  gauze  plug  and  from 
the  bottom  of  the  sinus  occupied  by  the  plug  "  frequently  yielded  a  number 
of  colonies  of  pyogenic  organisms. 

3.  Injections  of  virulent  cultures  of  Staphylococcus  aureus  into  the  tis- 
sues and  into  the  peritonaeal  cavity  were  not  followed  by  suppuration  nor  by 
peritonitis. 

4.  Operations  upon  bone  abscesses,  the  walls  of  which  it  is,  perhaps,  never 
possible  to  thoroughly  disinfect,  and  upon  suppurating  wounds  of  the  soft 
parts  which  likewise  cannot  be  thoroughly  disinfected  were  usually  attended 
by  perfect  organization  of  the  blood  clot. 

5.  Many  wounds  heal  primarily  when  no  antiseptic  precautions  whatever 
have  been  taken. 

6.  The  majority  of  subcutaneous  wounds  in  preantiseptic  times  were  not 
followed  by  suppuration. 

7.  The  wounds  of  most  surgeons  heal  as  a  rule  primarily  up  to  the  drain- 
age tubes. 

Ad.  1.  From  the  numerous  experiments  which  we  made  about  one  year 
ago  on  disinfection  of  the  skin  we  conclude  that  it  is  impossible  to  thor- 
oughly disinfect  it  by  any  of  the  methods  which  have  hitherto  been  recom- 
mended, and  that  it  would  at  least  consume  much  time  to  do  so  even  occa- 
sionally by  any  of  the  means  at  our  disposal. 

In  some  instances  we  have  subjected  the  skin  to  a  rigorous  disinfection 
for  four  days.  Then  test-tube  inoculations  were  made  from  scrapings  of 
the  skin  over  the  part  to  be  operated  upon.  In  every  case  we  have  had  the 
dissatisfaction  of  finding  at  least  three  or  four  colonies  in  each  of  the  inocu- 
lated tubes.   Staphylococcus  aureus  was  one  of  the  prevailing  organisms. 

u  It  was  not  until  the  fall  of  1889  that,  for  clean  wounds,  we  discarded,  absolutely, 
drainage  in  all  of  its  forms.  Since  September,  1890,  we  have  closed,  without  drainage, 
all  wounds— the  suppurating  as  well  as  the  clean  wounds. 


THE  TEEATMENT  OF  WOUNDS  101 

Profound  constitutional  effects  have  sometimes  followed  the  not  very 
prolonged  [from  10  to  12  hours]  application  to  the  skin  of  carbolic  solu- 
tions as  weak  as  1-60. 

We  have  made  many  experiments  on  the  disinfection  of  the  hands.  On 
several  occasions  forty-five  minutes  were  devoted  to  the  disinfection  of  one 
pair  of  hands  and  without  success.  Within  the  past  few  months  Dr.  Koose, 
one  of  my  assistants,  and  Dr.  Ghriskey,  one  of  Dr.  Kelly's  assistants,  have 
continued  the  experiments  on  hand  disinfection  under  the  supervision  of 
Dr.  A.  C.  Abbott  and  confirm  our  work  of  last  year.  The  work  of  all  who 
have  written  on  the  subject  of  hand  disinfection  has  probably  been  charac- 
terized by  one  and  the  same  fault.  The  scrapings  from  under  the  nails  and 
from  other  places  which  have  been  used  for  test  tube  inoculations  were 
perhaps  saturated  with  the  solution  used  for  disinfection  or  at  least  con- 
tained enough  of  the  disinfectant  to  inhibit  the  growth  of  microorganisms. 
We  found  that  hands  which  had  been  soaked  in  a  corrosive  sublimate  solu- 
tion [1-1000]  and  were  then  washed  with  two  litres  of  sterilized  water  still 
became  quite  black  when  immersed  in  a  solution  of  ammonium  sulphide. 
In  all  of  our  experiments,  therefore,  we  have  profited  by  the  work  of 
Geppert19  and  have  precipitated  the  mercury  before  making  the  test  tube 
inoculations.  Hands  which  have  been  besmeared  with  a  fluid  culture  of 
some  microorganism  can  undoubtedly  be  so  disinfected  or  washed  so  clean 
of  the  given  microorganism,  that  no  colonies  of  it  will  develop  in  the  finger 
prints  on  a  Petri's  plate,  and  the  nails  of  three  or  four  fingers  may  in  ten  or 
fifteen  minutes  be  so  well  attended  to,  that  scrapings  from  the  specially 
prepared  places  may  be  sterile.  But  to  disinfect  absolutely  all  parts  of  both 
hands  is  a  different  problem  and  one  that  has  not  been  solved.  In  not  a 
single  instance  have  we  succeeded  in  disinfecting  the  hands.  The  nearest 
approach  to  a  perfect  disinfection  was  made  by  the  operating  room  nurse. 
On  one  occasion,  when  she  had  devoted  nearly  one  hour  to  her  hands,  scrap- 
ings were  made  from  four  places.  Four  Esmarch  tubes  were  made  with  these 
scrapings.  Three  of  the  tubes  remained  sterile.  In  the  fourth  tube  there  was 
one  colony  of  a  long  slender  bacillus.  Ordinarily  from  three  to  six  and 
sometimes  many  more  colonies  appeared  in  each  of  the  tubes  inoculated 
with  scrapings  from  hands  which  had  been  disinfected  for  45  minutes.  We 
believe  that  it  is  possible  to  disinfect  the  hands  and  hope  that  others  may 
be  stimulated  by  our  results  to  investigate  the  subject  of  hand  and  skin 
disinfection  afresh  and  with  other  disinfectants. 

If  it  were  possible  to  sterilize  the  hands  of  the  operator  and  his  assistants 
and  the  skin  of  the  patient,  the  surgical  technique  might  be  made  a  practi- 
cally perfect  one.  The  danger  of  infection  from  the  air  is  probably  a  theo- 

"  Geppert,  Berliner  klin.  Wochenschr.  Nos.  37  and  38,  1889. 


102  THE  BLOOD  CLOT 

retical  and  not  a  real  danger.  We  have  exposed  for  hours  large  Petri's 
plates — ten  or  twelve  at  a  time — to  the  air  of  the  operating  room  before, 
during  and  after  operations  and  have  never  found  a  single  colony  of  pyo- 
genic microorganisms. 

Ad.  2.  Having  assured  ourselves  of  the  fact  that  our  technique  was 
necessarily  imperfect  we  became  much  interested  in  the  test  tube  inocula- 
tions made  from  the  surface  of  wounds  which  had  healed  throughout  by  first 
intention  and  from  the  bottom  of  sinuses  occupied  by  the  small  gauze  drains 
of  wounds  which  had  healed  without  suppuration.  These  inoculations  were 
made  at  the  first  dressing.  Not  more  than  one-half  of  the  tubes  remained 
sterile.  It  was  interesting  to  observe  that  the  sinuses  which  at  the  first  dress- 
ing furnished  pyogenic  microorganisms  were  often  found  to  be  perfectly 
healed  at  the  second  dressing.  The  tearing  of  the  granulations  by  the  with- 
drawal of  the  gauze  plugs  provided  many  of  the  sinuses  with  blood  clots 
which  became  organized  notwithstanding  the  presence  of  the  pus-producing 
germs.  The  organization  of  the  exudates  which  filled  the  other  sinuses  took 
place  as  perfectly  as  did  that  of  the  blood  clots. 

Ad.  3.  We  experimented20  almost  exclusively  with  Staphylococcus 
aureus,  and  always  with  cultures  the  virulence  of  which  we  had  determined 
by  inoculations  into  the  ear  veins  of  rabbits. 

Inoculations  of  the  Peeitonaeal  Cavity  with  Pure  Cultubes  of 
Staphylococcus  aureus 

The  peritonaeal  cavity  was,  in  each  instance,  opened  by  an  incision  three 
or  four  cm.  long  through  the  linea  alba.  The  wounds  were  closed  by  two 
rows  of  buried  sutures  and  dressed  with  celloidin. 

Group  I.  2  dogs.  Experiment.  A  small  piece  of  potato  covered  with  a 
thick  growth  of  Staphylococcus  aureus  [culture  No.  1]  was  introduced  into 
the  peritonaeal  cavity.    Both  dogs  died  of  general  peritonitis. 

Group  II.  13  dogs.  Experiment.  One  c.  cm.  of  a  bouillon  culture  of 
Staphylococcus  aureus  [culture  No.  1]  was  introduced  into  the  peritonaeal 
cavity.  Peritonitis  did  not  develop  in  a  single  case. 

Group  III.  10  dogs.  Experiment.  One  c.  cm.  of  a  bouillon  culture  of 
Staphylococcus  aureus  [culture  No.  2]  was  introduced  into  the  peritonaeal 
cavity.   Peritonitis  did  not  develop  in  a  single  case. 

Group  IV.  5  dogs.  Experiment.  A  small  piece  of  sterilized  potato  was 
introduced  into  the  peritonaeal  cavity.  Peritonitis  did  not  develop  in  a  single 
case.  The  pieces  of  potato  were  usually  found  adherent  to  the  great  omen- 
tum and  covered  by  a  transparent  and  almost  invisible  film  of  connective 
tissue. 

*°  Our  bacteriological  experiments  were  made  in  the  Pathological  Laboratory  of  The 
Johns  Hopkins  University. 


THE  TREATMENT  OF  WOUNDS  103 

Group  V.  7  dogs.  Experiment.  A  small  piece  of  potato  covered  with 
a  thick  growth  of  Staphylococcus  aureus  [culture  No.  2]  was  introduced 
into  the  peritonaeal  cavity.   All  of  the  dogs  died  of  general  peritonitis. 

Group  VI.  8  dogs.  Experiment.  A  small  piece  of  omentum  was  lig- 
ated  with  strong  silk.  The  ligature  and  the  tied  off  portion  of  the  omentum 
were  inoculated  with  a  drop  or  two  of  a  bouillon  culture  of  Staphylococcus 
aureus.  There  was  fatal  peritonitis  in  two  cases,  and  circumscribed  perito- 
nitis in  two  cases.  Four  of  the  dogs  recovered  without  peritonitis. 

Injections  of  Pure  Cultures  of  Staphylococcus  aureus  into  the 
Muscles 

Group  I.  2  dogs.  Experiment.  Ligated  the  left  femoral  vein  and 
artery  about  two  cm.  below  Poupart's  ligament  and  injected  one  c.  cm.  of  a 
bouillon  culture  of  Staphylococcus  aureus  into  the  muscles  of  the  left  leg. 
Within  twenty-four  hours  there  were  oedema  of  the  left  leg  and  induration 
and  tenderness  at  the  seat  of  injection.  Within  three  days  the  oedema  had 
disappeared.  Within  a  week  the  local  tenderness  and  induration  had  also 
disappeared.  In  neither  case  did  an  abscess  develop. 

Group  II.  7  dogs.  Experiment.  Ligated  the  right  femoral  artery  and 
injected  one  c.  cm.  of  a  bouillon  culture  of  Staphylococcus  aureus  into  the 
muscles  of  the  right  leg.  Within  twenty-four  hours  there  were  in  all  cases 
a  hard  swelling  and  tenderness  at  the  seat  of  injection.  In  no  case  was  there 
oedema  of  the  right  leg,  and  in  no  case  did  an  abscess  develop. 

Group  III.  6  dogs.  Experiment.  Ligated  the  left  femoral  vein  and 
injected  one  c.  cm.  of  a  bouillon  culture  of  Staphylococcus  aureus  into  the 
muscles  of  the  left  leg.  In  all  of  the  cases  there  supervened  an  oedema  of  the 
left  leg  and  a  local  tenderness  and  swelling  at  the  seat  of  the  injection.  In 
no  case  did  an  abscess  develop. 

Injections  of  the  Exudate  of  a  Purulent  Peritonitis  into  the  Skin 

Two  dogs.  Three  c.  cm.  were  injected  into  the  skin  over  the  knees  of  both 
dogs.  Only  a  slight  reaction  followed  the  injections. 

Ad.  4.  It  is  our  practice  now  to  treat  without  drainage  not  only  clean 
wounds,  but  also  almost  every  suppurating  wound.  The  walls  of  old  ab- 
scesses and  sinuses  are  excised  or,  when  excision  is  impracticable,  scraped. 
The  cutting  and  scraping  must  be  done  conscientiously  and  with  great 
patience.  The  Esmarch  bandage  is  of  service  in  these  operations.  Irriga- 
tions, which  we  have  abolished  for  clean  wounds,  may  be  used  freely  in 
these  suppurating  cases  before  the  Esmarch  bandage  is  removed.  The  sup- 
purating wounds  are  carefully  painted  with  pure  carbolic  acid,  loosely 
stitched  with  interrupted  buried  skin  sutures  and  covered  with  gutta-percha 
tissue.  There  is  often  considerable  dead  space  in  the  wounds  made  for  the 
cure  of  many  and  long  old  sinuses.  The  dead  spaces  become  filled  with 
blood  after  the  operation.  The  inflamed  skin  surrounding  the  orifices  of  the 
old  sinuses  having  been  cut  away,  the  provision  for  the  escape  of  the  blood 


104  THE  BLOOD  CLOT 

from  such  wounds  is  usually  more  than  sufficient.  The  dressings  are  very 
large  and  loosely  applied.  If  the  wound  is  between  two  joints  it  is  well  to 
immobilize  both  of  these  joints.  I  believe  that  it  is  particularly  important 
to  prevent  a  breaking  up  of  the  blood  clot  in  suppurating  cases.  The  tech- 
nique in  these  cases  is  necessarily  far  from  perfect.  The  wounds,  neverthe- 
less, heal  as  a  rule  in  the  typical  way.  We  must  conclude  that  we  are  in- 
debted to  the  tissues  as  well  as  to  the  antiseptics  for  our  good  results. 

Ad.  5.  Wounds  of  parts  which  are  rich  in  blood  vessels  usually  heal  by 
first  intention  even  when  no  antiseptic  precautions  have  been  taken.  Opera- 
tions on  the  face  and  perineum  are  notably  successful.  The  pyogenic  micro- 
organisms succumb  to  tissues  in  which  the  circulation  is  so  active. 

Ad.  6.  The  majority  of  subcutaneous  wounds  of  preantiseptic  times  were 
surely  infected.  Subcutaneous  wounds  were  made  with  knives  which  had 
never  been  disinfected  and  which  perhaps  for  years  had  been  used  to  incise 
abscesses.  But  the  subcutaneous  wounds  rarely  suppurated.  Open  wounds, 
on  the  other  hand,  suppurated  with  great  regularity.  If  an  open  wound 
were  to  be  distinguished  from  a  closed  wound  merely  by  the  length  of  the 
incision,  we  might  accept  the  generally  received  explanations  for  the  sup- 
puration of  the  former.  I  believe  that  the  immediate  cause  of  the  suppura- 
tion is  usually  the  rough  manipulation  of  the  infected  tissues  and  the 
strangulation  of  the  tissues  by  infected  ligatures  and  sutures. 

Ad.  7.  Few  surgeons  now-a-days  have  a  technique  bad  enough  to  prevent 
the  union  of  raw  surfaces  which  have  a  good  circulation,  if  the  dead  spaces 
have  been  thoroughly  drained  and  if  the  tissues  have  not  been  constricted 
by  ligatures  and  sutures. 

THE  TREATMENT  OF  WOUNDS. 
The  Management  of  the  Dead  Spaces 

Whether  a  surgeon  disinfects  by  carbolic  acid,  corrosive  sublimate  or  by 
steam ;  whether  he  uses  catgut  or  silk  for  his  sutures  and  ligatures ;  what 
material  he  uses  for  his  dressings ;  whether  the  dressings  are  simply  steril- 
ized by  heat  or  impregnated  with  antiseptics,  are  matters  of  minor  impor- 
tance to  the  patient. 

Of  great  consequence  is  The  Management  of  the  Dead  Spaces  in  Wounds. 
These  may  be  obliterated,  drained  or  allowed  to  fill  with  blood. 

The  more  imperfect  the  technique  of  a  surgeon  the  greater  the  necessity 
for  drainage.  The  most  rigid  antiseptic  precautions  are  demanded  for  the 
obliteration  treatment  of  dead  spaces :  the  buried  sutures  employed  to  ob- 
literate the  dead  spaces  necessarily  enfeeble  the  circulation  and  impair  the 
vitality  of  tissues  which  otherwise  might  be  able  to  dispose  of  large  quan- 
tities of  microorganisms. 


THE  TREATMENT  OF  WOUNDS  105 

It  is  doubtful  if  one  ever  obliterates  absolutely  the  dead  spaces  of  a  wound : 
and  certainly  most  undrained  wounds  contain  small  blood  clots  however 
patient  and  conscientious  and  skillful  the  attempts  at  obliteration  may 
have  been.  Upon  the  organization  of  small  blood  clots,  therefore,  depends 
more  or  less  the  healing  of  all  undrained  wounds. 

But  the  unintended  blood  clot  of  an  incompletely  obliterated  dead  space 
is,  I  think,  much  more  likely  to  decompose  than  the  intended  blood  clot 
because  it — the  former — lies  in  tissues  the  circulation  of  which  has  been 
interfered  with  by  buried  sutures,  and  in  a  wound  which  is  particularly 
exposed  to  the  dangers  of  strangulation  and  tension. 

The  blood  clot  treatment  of  dead  spaces  has  the  following  advantages : 

1.  Tissue  defects  are  beautifully  repaired.21 

2.  Obliteration  sutures  are  dispensed  with. 

SUTUEES  AND  LlGATUKES 

I  believe  that  the  obstruction  to  the  circulation  produced  by  sutures  and 
ligatures  is  often  the  immediate  cause  of  suppuration  in  infected  wounds, 
and  that  the  larger  the  masses  of  tissue  constricted  and  the  tighter  the 
strangulation  the  greater  the  danger  of  suppuration.  The  complete  strangu- 
lation of  large  masses  of  tissue  we  try  to  avoid  by  using  very  weak  silk  for 
the  sutures  and  ligatures. 

The  occasional  breaking  of  the  silk  reminds  one  that  he  is  tying  with  too 
much  force  or  that  he  has  included  too  much  tissue  in  his  ligature.  We  use 
the  finest  black  sewing  silk — Nos.  00,  0  and  a.  For  large  arteries  we  some- 
times double  the  fine  silk,  and  for  deep  sutures  we  often  use  the  coarser 
numbers.  Inasmuch  as  we  cannot  disinfect  the  skin  thoroughly,  we  never 
perforate  the  skin  with  a  suture.  The  skin  wound  is  invariably  closed  by 
"  buried  skin  sutures."  These  sutures  are  taken  from  the  under-surf ace  of 
the  skin.  They  are  fully  described  in  the  Bulletin  of  The  Johns  Hopkins 
Hospital.21 

We  consider  these  sutures  an  important  contribution  to  the  technique  of 
surgery.    The  wounds  are  not  exposed  to  the  suppuration  which  so  often 

n  Experiment  upon  a  dog.  We  removed  a  piece  of  the  triceps  muscle  and  trephined 
the  external  condyle  of  the  humerus.  The  wound  was  allowed  to  fill  with  blood  and 
was  covered  with  gutta-percha  tissue.  No  stitches  were  taken.  The  extremity  was 
immobilized  in  a  plaster  of  Paris  splint.  In  three  weeks  the  plaster  was  removed.  The 
defect  in  the  bone  was  so  perfectly  repaired  that  it  was  impossible  to  see  with  the 
naked  eye  a  line  of  demarcation  between  the  old  tissue  and  the  new. 

22  These  stitches  do  not  perforate  the  skin,  and  when  tied  they  become  buried.  They 
are  taken  from  the  under  side  of  the  skin,  and  made  to  include  only  its  deep  layers — 
the  layers  which  are  not  occupied  by  sebaceous  follicles.  Johns  Hopkins  Hospital 
Bulletin,  vol.  i,  p.  13. 


108 


THE  BLOOD  CLOT 


and  washed  for  a  few  minutes  with  a  hot  solution  of  corrosive  sublimate, 
1-1000. 

The  Opeeation 

The  operator  and  two  of  his  assistants  are  protected  from  the  bystanders 
by  the  semicircular  instrument  table  (vid.  Fig.  10).  The  assistant  who 
passes  the  instruments  wears  thin  rubber  gloves  which  are  disinfected  in  a 
corrosive  sublimate  solution.  The  only  hands  which  come  in  contact  with 
the  wound  are  those  of  the  operator.  The  sponging  is  done  by  the  operating 


Fig.  10. — The  Semicircular  Instrument  Table  and  the  Operating  Table. 

room  nurse  who  wrings  dry  the  sponges,  one  at  a  time,  as  they  are  required. 
The  pieces  of  gauze  used  for  sponging  are  kept  in  a  solution  of  corrosive 
sublimate,  1-1000.  "We  consider  it  unsafe  to  use  sponges  which  have  been 
sterilized  simply  by  steam  unless  the  top  of  the  sterilizer  be  removed  and 
replaced  each  time  that  a  sponge  is  required.  It  surely  is  not  safe  to  expose 
on  a  table  or  in  a  basin  the  dry  sterilized  sponges  to  the  many  dangers  of 
infection  from  contact. 

Irrigation  is  employed  only  in  suppurating  cases.  We  have  ascertained 
from  our  experiments  on  dogs  that  irrigation  with  solutions  of  corrosive 
sublimate  as  weak  as  1-10,000  produces  a  superficial  necrosis.  Wounds 
which  have  been  freely  irrigated  with  solutions  of  corrosive  sublimate  not 


THE  TKEATMEISTT  OF  WOUNDS  109 

stronger  than  1-5000,  or  moderately  irrigated  with  solutions  as  strong  as 
1-1000,  do  not  unite  throughout  by  first  intention.  The  wound  in  the  skin 
unites  and  the  divided  ends  of  the  muscles  unite,  but  the  skin  is  separated 
from  the  muscles  by  a  thin  serous  or  serofibrinous  exudate.  The  cavity 
which  contains  this  exudate  is  lined  by  a  film  of  necrotic  tissue  thick  enough 
to  be  seen  with  the  naked  eye.  Little  cavities  filled  with  the  same  exudate 
are  found  occasionally  in  the  connective  tissue  planes  between  the  muscles. 

The  tissues  are  handled  very  delicately  in  operating.  We  avoid,  if  possi- 
ble, the  tearing  of  the  tissues,  and  the  strangulation  of  the  tissues  by  liga- 
tures and  sutures.  Large  dead  spaces  are  sometimes  partially  obliterated 
by  buried  sutures:  as  a  rule  the  dead  spaces  are  allowed  to  take  care  of 
themselves.  The  wound  is  closed  with  interrupted  buried  skin  sutures  so 
placed  as  to  preclude  the  danger  of  distention.  The  dressing  is  so  applied 
that  it  shall  exert  a  gentle,  even  pressure.  I  have  said  that  "  I  conceive  an 
ideal  wound  to  be  one  which  immediately  after  the  operation  is  reduced  to 
the  condition  of  a  non-penetrating,  subcutaneous  wound,  and  which  is  as 
free  as  this  is  from  the  dangers  of  infection.  A  wound  which  has  been  irri- 
gated with  solutions  of  carbolic  acid,  corrosive  sublimate  or  other  disinfec- 
tants labors  under  the  disadvantage  of  a  more  or  less  extensive  area  of 
superficial  necrosis  from  which  the  subcutaneous  wound  is  free.  The  sub- 
cutaneous wound  is  not  exposed  to  the  dangers  which  attend  the  introduc- 
tion of  drainage  tubes,  ligatures  and  sutures,  nor  to  the  greatest  of  all 
dangers  for  the  surgeon's  wound,  that  of  infection  from  the  hands  of  the 
operator  and  his  assistants." 

We  have  reduced  our  wounds  almost  to  the  condition  of  non-penetrating, 
subcutaneous  wounds.  They  are  neither  irrigated  nor  drained.  The  chief 
danger  from  sutures  is  eliminated  by  the  employment  of  the  buried  skin 
sutures.  The  strangulation  of  the  tissues  is  to  a  great  extent  avoided  by  care 
in  the  application  of  the  ligatures  and  sutures  and  by  the  use  of  very  fine 
silk.  The  hands  of  the  surgeon  are,  as  a  rule,  the  only  hands  which  touch 
the  wound,  and  these  are  disinfected  in  the  manner  described.  The  instru- 
ments are  passed  by  the  gloved  hands  of  a  trustworthy  assistant;  and  the 
sponging  is  done  by  a  well-trained,  operating  room  nurse  who  takes  them, 
one  by  one,  as  they  are  required,  from  the  corrosive  sublimate  solution. 
I  am  under  great  obligations  to  Dr.  A.  C.  Abbott  for  instructing  in  bac- 
teriology the  operating  room  nurse  and  all  of  my  assistants,  and  for  super- 
vising and  taking  the  keenest  interest  in  our  bacteriological  work.  All  of 
the  preparations  for  the  operations — the  recrystallization  and  weighing  of 
the  corrosive  sublimate  for  the  solutions,  the  selection  and  sterilization  of 
the  instruments,  the  preparation  and  sterilization  of  the  silk  and  the  dress- 
ings, the  final  disinfection  of  the  patient — were  intrusted  to  the  operating 
room  nurse. 


110 


THE  BLOOD  CLOT 


The  Operating  Boom 

The  floors,  shelves  and  tables  of  the  operating  room  are  impregnated  with 
paraffine.  For  the  tables  and  shelves  the  paraffine  is  melted  and  rubbed  in 
with  a  hot  iron.  For  the  floor  the  paraffine  is  dissolved  in  turpentine  and 
painted  on  with  a  brush. 

The  Opeeatln-g  Table 

The  patients  are  anaesthetized  on  long,  narrow  boards.  They  are  then 
arranged  for  the  operation,  strapped  to  their  boards  and  transferred  with 


Fig.  11.— The  Operating  Table. 


them  to  the  top  of  a  shallow  sink  on  four  legs.  This  sink  is  about  20  cm. 
wider  and  45  cm.  shorter  than  the  board  {vid.  Fig.  11).  By  shifting  the 
board  the  side  gutters  can  at  any  moment  be  made  as  wide  as  may  be  desired. 
For  operations  on  the  head  and  feet  the  board  is  shifted  in  a  longitudinal 
direction,  far  enough  to  make  a  gutter  at  the  head  or  foot  as  well  as  at  the 
sides  of  the  board.  The  end  of  the  board  which  falls  within  the  end  of  the 
sink  is  supported  on  a  small  loose  block  which  is  placed  on  the  floor  of  the 
sink.   The  floor  of  the  sink  drains  to  a  hole  in  its  centre. 

The  perineal  board  (vid.  Fig.  12),  is  about  18  cm.  shorter  than  the  sink. 
The  height  of  the  patient's  buttocks  is  regulated  by  the  shoulder  yoke.  By 
pushing  the  yoke  up  the  inclined  plane  the  perineum  of  the  patient  can  be 


THE  TREATMENT  OF  WOUNDS  111 


Fig.  12.— The  Operating  Table  with  its  Perineal  Board. 


Fig.  13.— The  Yoke  of  the  Perineal  Board. 


112  THE  BLOOD  CLOT 

raised  to  the  level  of  the  standing  operator's  eyes  and  the  patient's  back  be 
exposed  up  to  the  shoulders.  The  yoke  (vid.  Figs.  12  and  13),  is  made  from 
a  solid  block  of  ash,  and  is  carved  to  receive  comfortably  the  head,  neck  and 
shoulders  of  the  patient.  The  patient's  legs  are  flexed  and  bear,  behind  the 
knees,  against  the  vertical  posts. 

The  posts  of  the  perineal  board  are  made  of  hickory.  The  table  and  all 
of  its  parts  are  made  of  ash  and  should  be  thoroughly  paraffined  six  or  more 
times  in  the  first  year. 

DESCRIPTION  OF  THE  PLATES. 

Plate  III. — The  wound  as  it  appears  at  the  first  dressing  after  an  operation  for  the 
removal  of  carcinoma  of  the  breast. 

The  open  wound  is  completely  filled  with  a  blood  clot. 

The  little  convexities,  0,  O,  and  X,  X,  of  the  skin  at  the  margin  of  the  clot  are 
caused  by  the  approximation  sutures  which  are  buried  in  the  clot.  The  white  spots 
at  the  upper  part  of  the  open  wound  represent  the  decolorized  parts  of  the  blood 
clot.  The  dark  spots  at  and  near  the  inner  edge  of  the  open  wound  represent  deeply 
pigmented  areas  of  the  blood  clot. 

This  case  illustrates  well  the  use  which  is  made  of  the  triangular  flap  to  cover  the 
defect.  The  apex  of  the  flap  was  originally  about  2.5  cm.  below  the  centre  of  the 
clavicle.  It  is  now  almost  on  the  line  of  the  nipples. 

Plate  IV. — The  wound  as  it  appeared  at  the  first  dressing  after  an  operation  for 
the  radical  cure  of  inguinal  hernia.  The  wound  extended  from  -f-  to  -J-. 

It  was  closed  with  buried  skin  sutures. 


PLATE    III 


PLATE   IV 


~ 


^ 


CRUSH  OF  ELBOW—  ORGANIZATION  OF  BLOOD  CLOT  * 

The  second  patient  you  will  recognize  as  one  whom  I  presented  to  you 
last  winter  to  illustrate  the  organization  of  a  very  large  blood  clot.  His  left 
elbow  had  been  run  over  by  one  or  more  wheels  of  a  horse  car,  about  thirty 
minutes  before  admission  to  the  hospital.  The  injury  sustained  was  about 
as  great  as  is  possible  in  such  an  accident.  The  elbow  felt  like  a  bag  of 
bones.  The  skin  was  broken  in  three  places,  and  was  very  badly  contused 
on  the  arm  and  forearm,  as  well  as  about  the  elbow.  At  the  operation,  the 
existing  wounds  were  enlarged,  and  lacerated  pieces  of  the  triceps  muscle, 
fragments  of  the  lower  end  of  the  humerus  and  the  olecranon  process  of 
the  ulna  were  removed.  Three  or  four  longitudinal  incisions  were  made 
through  the  skin,  which  was  undermined  in  all  directions.  The  oozing  of 
blood,  which  was  considerable,  was  purposely  not  checked.  The  wound  was 
allowed  to  fill  with  blood.  No  stitches  were  taken.  The  arm,  elbow,  and 
the  upper  part  of  the  forearm  were  wrapped  with  strips  of  protective  about 
one  inch  wide.  The  usual  dressing  of  sterilized  gauze  was  applied  and  the 
arm  was  fixed  in  an  extended  position.  I  exhibited  the  elbow  to  you  at  the 
second  dressing  when  the  granulations  had  just  reached  the  surface  of  the 
blood  clot  in  some  places. 

It  is  now  seven  months  since  the  operation.  The  patient  has  a  perfect 
joint,  as  you  may  see.  He  can  flex,  extend,  pronate  and  supinate  about  as 
well  as  he  ever  could.  I  consider  this  to  be  one  of  the  best  blood  clot  cases 
that  we  have  had.  The  clot  must  have  been  as  large  as  a  man's  fist. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  October  20, 
1890. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1890,  i,  111-112. 


113 


PLASTIC  OPERATION  FOR  THE  OBLITERATION  OF  A  LARGE 
CAVITY  IN  THE  LOWER  END  OF  THE  FEMUR ' 

W.  L.  Coddington,  aet.  30,  was  admitted  to  the  hospital  September  15, 
1891.  Twenty  years  ago,  and  shortly  after  a  fall  upon  the  right  knee,  the 
patient  suffered  from  an  acute,  circumscribed  osteomyelitis  of  the  lower 
end  of  the  right  femur.  The  pus  quickly  made  its  way  through  the  skin  a 
little  above  the  inner  condyle  of  the  femur.  A  year  later  a  small  piece  of 
bone  was  discharged  through  this  opening  in  the  skin.  Fifteen  years  ago 
the  skin  on  the  outer  side  of  the  thigh  a  little  above  the  knee  joint  was  per- 
forated and  through  this  second  opening  several  pieces  of  bone  escaped. 
The  patient  has  within  the  past  two  or  three  years  been  twice  operated  upon 
by  well-known  surgeons.  On  admission  the  lower  end  of  the  right  femur 
is  much  enlarged.  The  soft  parts  above  the  joint  are  thick  and  hard  and 
perforated  in  three  places,  in  front,  above  the  internal  condyle  and  above 
the  external  condyle.  Through  each  of  the  openings  the  probe  enters  the 
cavity  in  the  lower  end  of  the  femur. 

Operation,  September  17,  1891. — A  long  anterior,  longitudinal  incision 
through  the  common  extensor  muscle  and  an  internal,  longitudinal  incision 
were  made.  Through  these  incisions  the  front  and  inner  walls  of  the  cavity 
were  so  cut  away  that  the  soft  parts  could  fall  into  the  cavity  and  almost 
obliterate  the  dead  space.  The  bony  wall  was  cleaned  with  a  spoon  and 
freshened  with  a  gouge  and  the  walls  of  the  three  sinuses  were  excised.  The 
dead  spaces  of  the  wound  were  allowed  to  fill  with  blood.  The  wound  was 
covered  with  gutta-percha  tissue  and  dressed  as  usual. 

The  wound,  as  you  may  see,  has  healed  in  the  typical  way.  In  this  case 
as  in  the  preceding  one  the  bony  wall  of  the  cavity  was  very  hard  and  unable 
to  furnish  vigorous  granulations.  Two  surgeons,  as  I  have  said,  operated 
upon  the  case  without  success.  It  seemed  inadvisable  therefore  to  repeat 
their  work.  An  unsuccessful  surgical  operation  upon  such  a  cavity  is  an 
injurious  surgical  interference.  For  to  each  scraping  the  bony  wall  responds 
with  a  feebler  crop  of  granulations.  A  plastic  operation  of  some  sort  was 
clearly  a  necessity  in  this  case,  and  the  plan  of  treatment  which  we  adopted 
promises  to  be  a  satisfactory  one. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  October  5, 
1891. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1891,  ii,  160-161. 


Ill 


A  SUPPUEATING,  COMPOUND,  COMMINUTED  PEACTUEE  INTO 
THE  ANKLE  JOINT  TEEATED  WITHOUT  DEAINAGE  ' 

William  Clark,  aet.  16,  was  admitted  to  the  hospital  September  29,  1891. 
A  day  or  two  before  admission,  while  attempting  to  board  a  freight  train, 
he  slipped  and  caught  his  left  foot,  he  does  not  know  how,  in  the  gear  of 
the  car  and  sustained  a  compound  fracture  of  both  malleoli.  On  admission 
the  boy  was  suffering  greatly.  His  temperature  was  39.4°  C,  his  pulse  132. 
The  left  foot,  ankle  and  leg  were  much  swollen.  There  was  an  angry  blush 
about  the  ankle  which  extended  downwards  to  the  toes  and  upwards  to  the 
middle  of  the  leg.  Over  the  inner  malleolus  was  a  transverse  wound  about 
6  cm.  long  through  which  projected  the  lower  inner  edge  of  the  shaft  (the 
upper  fragment)  of  the  broken  tibia.  Both  malleoli  were  broken  square  off. 
There  was  some  comminution  of  the  inner  malleolus  and  of  the  lower  end 
of  the  tibia.   The  joint  was  suppurating. 

Operation. — The  ankle  joint  was  fully  exposed  by  the  usual  external 
lateral  incision.  Through  this  incision  the  cartilage  was  sawed  off  from  the 
tibia,  the  astragalus  exsected  and  the  cartilage  chiseled  away  from  upper  sur- 
face of  the  os  calcis.  A  longitudinal  incision  into  the  joint  was  then  made 
from  the  inner  side.  Through  this  incision  the  fragments  of  the  internal 
malleolus  and  of  the  tibia  were  extruded.  A  few  additional  longitudinal 
incisions  were  made  through  the  tissues  which  were  particularly  tense. 
Then  a  slow  but  vigorous  massage  was  practised  for  some  minutes  to  relieve 
the  tissues  of  the  great  tension  which  existed.  I  was  surprised  at  the  rapid- 
ity with  which  the  serum  escaped  through  the  cuts  and  at  the  amount  of 
the  transudate.  In  a  few  minutes  the  swelling  of  the  foot,  leg  and  ankle 
was  dissipated.  Had  it  not  been  for  these  long  and  numerous  cuts  we  should 
have  been  obliged  to  remove  the  Esmarch  bandage  before  practising  the  mas- 
sage. The  propriety  of  exercising  massage  in  such  a  case  without  the 
Esmarch  bandage  might  be  questioned.  The  Esmarch  was  removed  tem- 
porarily to  enable  us  to  ligate  the  larger  vessels.  It  was  then  replaced  for 
the  final  disinfection  of  the  wound ;  the  leg  was  placed  in  a  bath  of  corrosive 
sublimate  (1-1000)  for  about  three  minutes,  and  then  in  a  bath  of  carbolic 
acid  (1-20)  for  about  three  minutes.  No  stitches  were  taken.  The  wounds 
were  covered  with  gutta-percha  tissue  and  the  dressing  applied  before  the 
Esmarch  bandage  was  removed. 

The  patient's  temperature  declined  rapidly  to  the  normal  point.  He  has 
not  had  an  unfavorable  symptom  since  the  operation. 

The  wound  is  dressed  tonight  for  the  first  time  since  the  operation.  You 
will  observe  that  there  is  no  redness  nor  swelling  of  the  limb. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  October  5, 
1891. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1891,  ii,  160-161. 

115 


116  ERACTTTKE  INTO  THE  ANKLE  JOINT 

The  blood  clots  are  more  or  less  completely  organized.  The  clot  which 
fills  the  ankle  joint  is  breaking  down  on  the  surface ;  but  in  a  week  or  ten 
days  the  granulations  will  everywhere  be  even  with  the  surface.  This  method 
of  treating  such  cases  is  surely  preferable  to  that  which  stuffs  the  dead  spaces 
with  gauze  or  drainage  tubes.  I  would  emphasize  the  following  points  in 
the  treatment  of  cases  like  this  one : 

1.  Excise  cartilaginous  surfaces  and  thus  avoid  having  dead  walls  for 
dead  spaces. 

2.  Make  free  antitension  incisions  to  relieve  tension  and  to  enable  one  to 
practise  massage  protected  by  the  Esmarch  bandage. 

3.  Eemove  the  Esmarch  bandage  temporarily  to  ligate  the  principal 


4.  Use  as  few  and  as  fine  ligatures  as  possible.  Avoid  tight  and  unneces- 
sary stitches. 

5.  Disinfect  the  limb,  protected  by  the  Esmarch  bandage,  just  before 
applying  the  dressing. 

6.  Apply  the  dressing  before  the  final  removal  of  the  Esmarch  bandage. 


THE 
SURGERY  OF  FOREIGN  BODIES 


EEMOVAL  OF  FOREIGN  BODIES1 

I.  A  PIECE  OF  FIBRO-CARTILAGE  REMOVED  FROM  THE  OESOPHAGUS 
BY  EXTERNAL  OESOPHAGOTOMY. 

II.  THREE  CALCULI,  EACH  WITH  A  PORTION  OF  A  SOFT  CATHETER  AS 
A  NUCLEUS,  REMOVED  FROM  THE  BLADDER  BY  LATERAL  LITH- 
OTOMY AT  ONE  OPERATION. 

III.  A  PORTION  OF  A  BULLET  REMOVED  FROM  THE  DIPLOE  AND 
CRANIAL  CAVITY. 

Case  I. — A  piece  of  fibre-cartilage  removed  from  the  oesophagus  by  ex- 
ternal oesophagotomy. — At  Ward's  Island,  July  23,  1882,  a  Hungarian, 
aged  thirty-three,  swallowed  at  dinner  a  piece  of  food  which  became  arrested 
in  his  oesophagus  a  little  below  the  cricoid  cartilage.  The  resident  physi- 
cians were  unsuccessful  in  their  attempts  to  dislodge  it.  They  obtained, 
however,  a  fragment  which,  submitted  to  microscopical  examination,  proved 
to  be  fibro-cartilage.  The  patient  was  said  to  have  experienced  great  diffi- 
culty in  breathing  for  several  hours,  and  then  to  have  become  quite  tolerant 
of  the  foreign  body,  but  to  have  been  unable  to  swallow  even  liquids. 

July  25th. — The  foreign  body,  indistinctly  definable  by  palpation  of  the 
neck,  was  believed  to  be  lodged  in  the  oesophagus,  just  above  the  sternum, 
projecting  more  to  the  right  side  than  to  the  left.  An  incision,  extending 
from  the  middle  of  the  thyroid  cartilage  to  the  interclavicular  notch  of  the 
sternum,  was  made  parallel  with  the  anterior  border  of  the  sternocleidomas- 
toid muscle.  The  oblique  jugular  vein  was  drawn  toward  the  median  line. 
The  middle  tlryroid  vein  in  the  upper  angle  of  the  wound  was  doubly  ligated 
and  divided.  The  common  carotid  artery,  crossed  by  the  omohyoid  muscle, 
rolled  up  into  view.  The  foreign  body  was  readily  mapped  out  through  the 
oesophageal  walls,  and  over  it  was  stretched  the  recurrent  laryngeal  nerve. 
An  incision  an  inch  and  a  quarter  long  was  made  into  the  oesophagus,  paral- 
lel with  and  posterior  to  the  nerve,  and  the  foreign  body,  measuring 
l|xlxl  inch,  was  removed  with  a  vulsella.  The  wound  in  the  oesophagus 
was  united  by  sulphurous  acid  catgut,  and  the  integument  by  silk  sutures. 
An  iodoformized  peat  dressing  was  applied.  A  few  days  later  the  patient  was 
clandestinely  served  with  blackberries  by  missionaries  to  the  island,  which 
interfered  with  union  by  first  intention,  but  otherwise  did  not  hinder  his 
prompt  recovery. 

Case  II. — Three  calculi,  each  with  a  portion  of  a  soft  catheter  as  a 
nucleus,  removed  from  the  bladder  by  lateral  lithotomy  at  one  operation. — 
The  patient,  a  Finn,  about  thirty-five  years  old,  had  been  in  the  habit  of 

1  Presented  at  the  New  York  Surgical  Society,  January  22,  1884. 
N.  York  M.  J.,  1884,  xxxix,  226-227. 
Also:  Med.  News,  Phila.,  1884,  xliv,  201. 

119 


120  SURGERY  OF  FOREIGN  BODIES 

evacuating  his  paralyzed  bladder  with  a  soft  catheter.  One  day  the  catheter 
broke  off  in  his  bladder,  and  a  piece,  believed  to  be  two  or  three  inches  long, 
was  left  behind. 

He  subsequently  regained  the  power  of  his  bladder,  and  applied,  six  or 
eight  months  after  the  mishap,  at  Ward's  Island,  for  relief  of  frequent  and 
painful  micturition.  A  stone  was  detected  by  Thompson's  searcher.  In 
consideration  of  the  history,  it  was  believed  to  be  advisable  to  practise  the 
cutting  operation.  The  patient  had  such  a  short  perinaeum  that  the  finger, 
introduced  into  the  bladder,  could  ascertain  the  number  and  shape  of  the 
stones.  These  were  carefully  seized  with  the  forceps  in  such  a  way  as  not  to 
be  crushed,  and  removed. 

The  patient's  convalescence  was  somewhat  protracted  because  of  a  cys- 
titis perpetuated  by  a  few  fragments,  which  he  eventually  passed  per 
urethram. 

Each  calculus  contained  a  piece  of  the  catheter,  its  point  being  distinctly 
visible  in  one  of  them. 

Case  III. — A  portion  of  a  bullet  removed  from  the  diploe  and  cranial 
cavity. — Mr.  H.  U.  G.,  aged  fifty-two,  was  admitted  to  the  Chambers  Street 
Hospital,  May  9,  1883,  for  a  self-inflicted  pistol-shot  wound  of  the  head. 

A  small  circular  scalp  wound  was  found  on  the  right  side,  two  inches  and 
a  half  below  the  sagittal  suture  and  one  inch  in  front  of  the  external  audi- 
tory meatus.  The  reflexes  were  normal,  and  there  was  no  paralysis;  the 
intellect  was  perfectly  clear. 

A  crucial  incision  was  made  through  the  scalp.  The  external  table  was 
found  depressed,  and  at  the  bottom  of  the  depression  there  was  a  hole  one- 
quarter  of  an  inch  in  diameter  and  about  one  inch  behind  the  bullet  wound 
in  the  soft  parts.  A  probe,  passed  obliquely  backward  through  the  hole, 
detected  the  foreign  body,  which  was  not  visible. 

Thereupon  certain  fragments  of  the  external  table  were  removed,  and 
the  bullet  was  revealed,  lying  between  the  two  tables,  and  projecting  some- 
what into  the  cranial  cavity.  Upon  its  extraction,  a  slightly  depressed  frag- 
ment of  the  inner  table  was  withdrawn. 

The  wound  was  dressed  antiseptically,  and  closed  with  a  continuous  cat- 
gut suture.  Union  took  place  by  first  intention  throughout,  except  where 
the  incisions  crossed  one  another — viz.,  at  the  point  of  entrance  of  the 
bullet — and  here  there  was  a  very  slight  necrosis  of  the  approximated 
corners  of  the  flaps. 

The  bullet  had  split  upon  the  outer  table  of  the  parietal  bone ;  one  frag- 
ment entered  the  diploe  and  cranial  cavity,  as  described,  and  the  other 
passed  through  a  mirror  and  was  found  behind  the  bureau. 


SUCCESSFUL  REMOVAL  OF  LAKGE  FOREIGN  BODY  FROM 
THE  HEAD1 

To  the  Editor  of  The  Philadelphia  Medical  Journal: 

In  connection  with  the  interesting  case  published  by  Dr.  Tiffany  of  the 
removal  of  a  chisel  from  a  man's  head,  the  following  notes  from  memory 
of  a  similar  case  upon  which  I  operated  years  ago,  may  be  of  interest : 

"  A  man,  about  40  years  old,  consulted  me  in  1882  or  1883  seeking  to 
be  relieved  of  chronic  nasal  catarrh,  nasal  voice  and,  I  think,  headache. 
Examination  of  the  nose  -resulted  in  the  discovery  of  a  piece  of  metal  very 
firmly  engaged  in  the  nose  and  imbedded  apparently  in  the  body  of  the  axis. 
The  patient  was  as  much  surprised  at  the  findings  as  I  was,  and  rejoiced  at 
being  able  to  confront  his  medical  advisers  with  evidence  which  sustained 
his  opinion,  frequently  expressed  to  them,  that  an  explosion  more  than  five 
years  before  had  in  some  way  caused  his  troubles.  He  had  been,  perhaps  for 
an  instant,  slightly  shocked  by  this  explosion,  but  had  felt  no  pain  and 
knew  that  he  had  been  injured  only  when  blood  began  to  trickle  down  his 
face  and  into  his  mouth.  The  surgeon  in  charge  discovered  a  transverse 
wound  of  the  skin  covering  the  bridge  of  the  nose,  which  he  promptly 
stitched,  securing  union  by  first  intention.  I  found  a  fine  linear  scar  in  the 
skin  just  below  the  articulation  between  the  frontal  and  nasal  bones,  and  a 
slight  deformity  of  the  bridge  of  the  nose.  A  few  days  after  the  first  visit 
of  the  patient  I  removed  by  an  osteoplastic  operation  through  cheek  and 
nose  an  irregularly  shaped  piece  of  steel  almost  as  large  as  a  dental  plate  for 
the  upper  jaw." 

It  was  only  after  exercising  a  great  amount  of  force  that  I  was  able  to 
dislodge  this  piece  of  steel  which  had  been  imbedded  for  so  many  years,  and 
I  know  that  at  the  time  I  considered  the  operation  a  hard  one,  and  was 
proud  of  the  result.  A  short  handle-like  projection,  bent  about  at  right 
angles  to  the  rest  of  the  plate,  was  held  in  a  way  to  make  extraction  of  the 
entire  piece  particularly  difficult.  Contemplating  the  plate  of  steel  after  its 
removal,  we  were  astonished  to  learn  that  such  a  large  foreign  body  could 
have  passed  through  a  wound  so  short  as  that  indicated  by  the  scar,  and 
have  caused  so  little  def ormity ;  for  the  nasal  bones,  and,  I  think,  one  at  least 
of  the  nasal  processes  of  the  superior  maxilla,  must  have  been  fractured. 
The  man  recovered  promptly  from  the  operation. 

1 A  letter  to  the  Editor  of  the  Philadelphia  Medical  Journal. 
Phila.  M.  J.,  1900,  v,  4.  (Reprinted.) 

121 


A  CONTRIBUTION  TO  THE  SURGERY  OF  FOREIGN  BODIES1 

I.  STELLATE    CALCULI    IN    FORM    RESEMBLING    JACKSTONES    RE- 
MOVED FROM  THE  BLADDER  BY  SUPRAPUBIC  LITHOTOMY. 
II.  TWO  HUNDRED  AND  EIGHT  FOREIGN  BODIES  AND  SEVENTY-FOUR 
GRAMMES  OF  GLASS  EXTRACTED  FROM  THE  STOMACH  BY  GAS- 
TROTOMY.  RECOVERY. 

I. — Large  stellate,  "  jackstone  calculi  "  removed  from  the  bladder  by  su- 
prapubic cystotomy. — B.  G.,  aet.  84,  was  admitted  to  The  Johns  Hopkins 
Hospital  December  9, 1891.  The  patient  was  too  feeble  to  give  a  clear  history 
of  his  case.  He  believed  that  until  about  a  year  ago  he  had  had  no  bladder 
symptoms.  At  this  time,  he  had,  as  he  called  it,  a  severe  attack  lasting  about 
one  month,  characterized  by  painful  and  difficult  micturition.  Patient  re- 
gained his  health,  he  stated,  and  could  get  about  quite  as  well  as  before, 
except  that  he  could  not  ride  horseback;  the  jolting  of  riding  produced  pain 
in  his  perinaeum  and  a  desire  to  urinate.  He  remained  well  until  the  present 
attack,  which  began  about  six  weeks  before  admission  and  was  almost  pre- 
cisely like  the  first  one.  He  now  micturates  two  or  three  times  an  hour  or 
oftener,  passing  from  10  c.  c.  to  50  c.  c  at  a  time. 

Examination. — Patient  is  emaciated;  his  mucous  membranes  are  pale; 
his  arteries  tortuous  and  rigid ;  he  has  a  conspicuous  arcus  senilis ;  his  blad- 
der is  distended  to  within  4  cm.  of  the  umbilicus ;  the  meatus  urinarius  is 
very  small ;  the  prostate  is  very  large. 

Urine. — Specific  gravity  1010;  albumin;  reaction  alkaline;  much  sedi- 
ment. In  sediment:  epithelial  cells,  a  few  red  corpuscles,  amorphous  urates 
and  numerous  triple  phosphate  crystals.  It  was  considered  inadvisable  to 
explore  the  bladder  with  an  instrument  before  operation  because  of  the 
patient's  very  feeble  condition. 

Operation,  December  11,  1891.  Suprapubic  cystotomy. — An  incision  into 
the  bladder  large  enough  to  admit  two  fingers  was  made,  and  five  calculi 
were  extracted  with  the  fingers  (see  Plate  V).  These  calculi  were  lying  free 
in  the  pouch  behind  the  prostate.  They  were  very  light  in  weight  and  light 
grayish-brown  in  color.  The  largest  calculus,  the  one  first  extracted,  re- 
sembled so  strikingly  the  ordinary  jackstone  that  the  five  stones  have  always 
been  referred  to  as  jackstone  calculi.  The  perfect  one  has  six  prongs  of 
about  equal  length,  joining  a  small  hub  at  the  centre;  these  prongs  are  so 
inserted  into  the  hub  that  each  one  is  at  right  angles  to  all  of  the  others, 
except  the  one  which  is  in  a  direct  line  with  it.  Each  prong  is  bifid  at  its 
tip.  The  smaller  stones  are  less  perfect,  but  they  appear  to  be  all  of  the 
same  type. 

1  Prepared  for  "  Contributions  to  the  Science  of  Medicine,  dedicated  by  his  Pupils 
to  William  Henry  Welch  upon  the  Twenty-Fifth  Anniversary  of  his  Doctorate." 
Johns  Hopkins  Hosp.  Rep.,  Bait.,  1900,  ix,  1047-1059.   (Reprinted.) 

122 


PLATE  V 


Vesical  Calculi  Removed 
December  1,  1891,  by  Supra- 
public  Cystotomy.  (Exact 
size.) 


SURGERY  OF  FOREIGN"  BODIES  123 

Last  summer  I  was  greatly  pleased  to  discover  in  the  Hunterian  Museum 
of  the  Royal  College  of  Surgeons,  London,  two  sets  of  minute  calculi  re- 
sembling closely  those  which  I  have  just  described.  There  are  twelve  in  one 
set,  and  fifteen  in  the  other.  All  of  the  stones  in  the  Museum  of  the  Royal 
College  are  much  smaller  than  mine  and  were  obtained  post  mortem  from 
the  kidney.  My  largest  stone  measures  3£  cm.  in  its  longest  diameter  and 
is  almost  perfectly  symmetrical.  Oliver  T.  Duke,  Esq.,  presented,  in  1868, 
the  set  of  fifteen  to  the  Museum  of  the  Royal  College  of  Surgery.  This 
set  is  labeled  C  78  in  the  museum  catalogue.  The  second  set,  presented  by 
J.  McCarthy,  Esq.,  is  labeled  C  lkh-  in  the  catalogue  of  the  museum,  and 
before  presentation  was  described  by  him  in  the  Medico-Chirurgical  Trans- 
actions, published  by  the  Royal  Medical  and  Chirurgical  Society  of  London, 
Vol.  LV,  1872,  p.  263.  Mr.  McCarthy  furnishes  a  plate  of  the  stones  and 
the  result  of  the  analysis  of  one  of  them.  Unfortunately  our  jackstone 
calculi  were  so  carefully  laid  away  by  some  one  before  a  chemical  analysis 
had  been  made  that  we  cannot  find  them.  Inasmuch  as  the  Medico- 
Chirurgical  Transactions  are  accessible  to  so  few  of  us,  and  Mr.  McCarthy's 
brief  description  of  his  calculi  is  so  admirable  and  interesting,  I  shall  quote 
what  he  says : 

"  In  February,  1872,  a  woman  was  admitted  into  the  London  Hospital 
under  the  care  of  Mr.  Couper  for  spontaneous  fracture  of  the  neck  of  the 
left  femur,  the  result  of  cancer,  which,  originating  in  the  uterus,  had  spread 
through  the  sacrosciatic  foramina  and  involved  the  soft  structures  round 
the  left  hip  with  the  upper  part  of  the  left  femur.  She  was  moribund  when 
admitted  and  there  was  nothing  to  attract  attention  especially  to  her  kid- 
neys, any  pain  that  she  complained  of  being  naturally  referred  to  the  disease 
of  the  uterus. 

*  She  died  soon  after  her  admission,  and  on  making  the  post-mortem 
examination  I  found  the  upper  part  of  the  pelvis  filled  with  a  cancerous 
mass  which  pressed  upon,  and  obliterated  her  left  ureter ;  on  removing  the 
left  kidney  and  making  a  section  in  the  usual  manner,  I  found  the  pelvis 
enormously  distended,  the  medullary  portion  almost  altogether  absorbed, 
and  the  cortical  substance  the  seat  of  acute  suppurative  nephritis.  The 
upper  part  of  the  left  ureter  was  occupied  by  a  large  conical  mulberry  cal- 
culus and  the  distended  pelvis  contained  eleven  calculi;  the  remarkable 
shape  of  which  induces  me  to  bring  them  under  the  notice  of  your  society. 

"  The  calculi  all  felt  soft  and  greasy  when  first  removed  from  the  kidney 
and  some  greatly  resembled  biliary  calculi.  The  projections  on  the  surface 
of  the  large  calculus  were  unusually  acuminated,  and  the  rest  consisted  of 
a  central  globular  body  with  four  or  five  prominent  spines.  In  five  the  cen- 
tral mass  was  about  the  size  of  a  black  currant,  and  the  spines  were  short 
and  stunted.  In  the  remaining  six  the  central  part  was  smaller  and  the 
spines  longer  and  more  tapering.  Three  had  a  very  symmetrical  tripod  base 
with  a  single  erect  central  spine.  The  other  three  had  much  the  same  gen- 
eral outline  but  with  one  or  more  additional  and  shorter  spines.   The  pelvis 


124  SURGERY  OF  FOREIGN  BODIES 

of  the  right  kidney  contained  a  single  oblong  spiculated  calculus  which  has 
been  analyzed  for  me  by  Dr.  Tidy,  assistant  to  the  Lecturer  on  Chemistry 
at  the  London  Hospital  Medical  College.  The  results  of  his  analysis  are  as 
follows : 

Moisture   9.55  per  cent. 

Oxalates    8.72        " 

Lithates   , 34.8 

Chlorine 3.22      " 

Sulphuric  acid 4.56        " 

Phosphates    a  trace. 

Fat  and  Cholesterine 3656  per  cent. 

Loss    2.59        " 


100.00 


"  Mr.  Curling  has  kindly  informed  me  that  there  is  a  somewhat  similar 
specimen  of  renal  calculi  in  the  museum  of  the  Royal  College  of  Surgeons. 
They  are  much  smaller,  with  very  fine  and  delicate  spines.  They  are  num- 
bered C  78  in  the  catalogue  and  are  described  as  being  composed  of  oxalate 
of  lime.  They  were  found  in  the  kidney  of  a  patient  in  whom  the  only 
noticeable  feature  during  life  was  albuminuria.  I  cannot  offer  any  explana- 
tion of  the  unusual  shape  of  these  calculi,  which  appear  to  be  too  symmetri- 
cal to  have  been  formed  accidentally." 

I,  too,  am  at  a  loss  for  an  explanation  of  the  form  of  these  calculi,  and, 
with  Mr.  McCarthy,  agree  that  something  more  than  accident  is  responsible 
for  their  symmetry.  I  did  not  extract  them  from  pockets  in  the  bladder 
wall.  We  were  not  permitted  to  make  an  autopsy  upon  our  patient,  who 
became  delirious  almost  immediately  after  the  operation,  had  suppression 
of  urine,  and  died  on  the  seventh  day. 

In  the  Hunterian  Museum  these  calculi  are  labeled  and  known  as  the 
oxalate  of  lime  calculi.  It  is  greatly  to  be  regretted  that  an  examination  of 
our  calculi  could  not  have  been  made ;  but  I  still  believe  that  some  day  they 
will  be  found. 

II. — Two  hundred  and  eight' foreign  bodies  and  7-4  grammes  of  glass  ex- 
tracted from  the  stomach  by  gastrotomy.  Recovery. — A.  S.,  aet.  21,  carpen- 
ter, was  admitted  to  the  medical  side  of  The  Johns  Hopkins  Hospital  on 
Wednesday  March  14,  1900.  The  patient  had  been  making  his  living  by 
swallowing,  or  pretending  to  swallow,  glass,  tacks,  etc.  His  present  illness 
dates  from  Saturday,  March  10th,  when  he  was  stripped  by  some  medical 
students  and  challenged  to  swallow  articles  in  their  presence  to  convince 
them  that  he  was  an  honorable  man  and  not  a  fake.  He  began  his  demon- 
stration at  7  p.  m.  Saturday  and  did  not  satisfy  his  diabolical  inquisitors 
until  2  o'clock  Sunday  morning.  About  2.45  a.  m.  on  Sunday  he  vomited 
dark  fluid,  but  none  of  the  ingested  foreign  bodies.  After  vomiting,  he 
experienced  a  sharp,  piercing  pain  in  the  epigastric  region  and  back.   He 


SUEGERY  OF  FOREIGN  BODIES  125 

has  attempted  to  take  his  food  regularly,  although  vomiting  followed  each 
meal.  The  distress  has  been  constant,  and  exacerbations  of  pain  are  often 
severe.  Patient  could  not  sleep  on  Sunday  night,  and  on  attempting  to 
start  to  work  on  Monday  morning,  he  suddenly  vomited.  Altogether  he 
vomited  twice  on  Monday,  twice  on  Tuesday,  and  once  on  "Wednesday  morn- 
ing; the  last  vomitus  was  very  green.  At  no  time  have  there  been  foreign 
bodies  in  the  vomitus.  Loose  greenish  stools  on  Sunday,  Monday  and  Tues- 
day contained  none  of  the  ingested  bodies. 

March  lJfth. — Patient  had  a  chill  yesterday  morning  followed  by  fever. 
He  complains  today  of  very  severe  pain  in  the  abdomen,  particularly  in  the 
epigastrium.  At  times  he  rolls  himself  about  in  bed  in  paroxysms  of  pain. 
The  abdomen  is  quite  flat  but  very  rigid.  The  respiratory  movements  are 
greatly  restricted.  All  of  the  abdominal  muscles  are  very  rigid,  but  nothing 
further  is  made  out  on  palpation. 

In  the  skiagraph  taken  just  before  the  operation,  the  stomach  is  sharply 
denned,  as  if  the  viscus  was  filled  with  a  shadow-casting  mass;  but  gentle 
palpation,  even  under  ether,  did  not  reveal  the  outlines  of  this  mass.  The 
reason  for  this  undoubtedly  was  that  the  foreign  bodies  occupying  chiefly 
the  deepest  part  of  the  fundus  of  the  stomach  anchored  it  in  suck  a  position 
that  it  could  not  readily  be  palpated,  and  at  least  could  not  be  distinguished 
clearly  from  the  vertebral  column  and  the  ribs. 

March  loth,  at  10  a.  m.,  I  saw  the  patient  for  the  first  time.  The  opera- 
tion, begun  at  10.30  a.  m.,  was  not  completed  until  1.45  p.  m.,  although  we 
worked  as  rapidly  as  possible.  Under  ether,  an  incision  was  made  through 
the  left  rectus  muscle ;  the  entire  hand  of  the  operator  was  introduced  into 
the  abdomen  and  the  stomach  palpated;  it  was  so  heavily  weighted  with 
the  mass  of  iron  that  it  could  not  be  drawn  up  into  the  wound,  and  I  was 
afraid  to  prop  it  up  from  behind,  lest  its  posterior  wall  should  be  perforated, 
or  at  least  injured,  by  some  of  the  sharp  foreign  bodies ;  so  drawing  gently 
on  the  anterior  wall  of  the  stomach,  I  succeeded  in  bringing  a  small  portion 
of  it  to  the  surface.  The  stomach  wall  was  thick  and  oedematous.  An  inci- 
sion into  the  cavity  of  the  stomach,  large  enough  to  admit  two  fingers,  was 
made,  after  the  abdominal  contents  had  been  very  carefully  walled  off  with 
large  quantities  of  gauze.  The  first  thing  extracted  was  a  steel  chain  re- 
sembling a  small  dog-chain;  with  it  came  numerous  small  pieces  of  glass 
and  some  blackish  mucus  stained  with  blood  and  iron  and  smelling  strongly 
of  iron.  For  fear  that,  during  our  manipulations,  which  evidently  would 
require  a  long  time,  we  should  let  fall  into  the  abdominal  cavity  some  of 
the  minute  fragments  of  glass,  I  sewed  a  strip  of  fine  linen  to  the  circum- 
ference of  the  wound  in  the  stomach,  thus  making  a  funnel,  in  which  to 
catch  even  the  finest  spiculae.  It  required  nearly  2£  hours  to  evacuate  all 
the  bodies  which  could  be  felt.  Several  times  I  believed  that  the  last  piece 
had  been  removed,  when  the  peristalsis  of  the  stomach  would  bring  some- 
thing more  within  reach.  I  was  much  aided  by  the  stomach  peristalsis,  for 
our  longest  forceps  could  not  reach  the  most  dependent  point  of  the  stomach. 
Finally  I  decided  to  sew  up  the  stomach,  because  it  seemed  impossible  to 
reach  anything  more  from  this  opening,  which  was  about  6  cm.  from  the 
greater  curvature,  and  perhaps  10  or  12  cm.  from  the  pylorus.  I  did  not 
introduce  my  hand  into  the  abdominal  cavity  to  explore  bimanually  for 


126  SUEGEEY  OF  EOEEIGN  BODIES 

additional  foreign  bodies,  fearing  to  infect  the  peritonaeal  cavity;  so  after 
sewing  up  the  stomach  wound  completely,  we  all  disinfected  our  hands 
thoroughly  and  made  a  fresh  toilet  of  the  abdominal  cavity;  then  on  pal- 
pating the  stomach  which  could  now  be  drawn  easily  into  the  wound  since 
almost  all  of  the  foreign  bodies  had  been  removed,  it  was  evident  that  a 
knife-blade  and  several  smaller  foreign  bodies  were  still  present  in  the 
stomach.  A  second  incision  was  then  made  in  the  stomach  much  nearer 
the  cardiac  orifice  than  the  first,  and  just  over  the  pouch  in  which  the  re- 
maining foreign  bodies  were  lodged,  and  from  this  second  incision,  which 
was  only  large  enough  to  admit  one  finger,  these  bodies  were  removed  in  a 
few  minutes.  This  stomach  wound  was  then  tightly  closed,  as  was  the  first, 
with  a  double  row  of  mattress  sutures.  The  mucous  membrane  of  the 
stomach  seemed  to  be  considerably  injured  by  the  foreign  bodies,  and  great 
care  was  exercised  in  the  extraction  of  these  bodies  lest  further  laceration 
of  the  stomach  wall  should  occur.  Many  of  the  bodies  during  the  operation 
were  removed  with  large  scoops,  but  most  of  them  with  forceps.  Blood  came 
away  with  each  scoopful  of  glass  and  tacks,  and  it  seemed  to  me  that  perhaps 
more  damage  resulted  from  the  employment  of  the  scoop  than  of  the  forceps. 
On  examining  the  Avails  of  the  stomach  after  the  operation  was  over,  two 
minute,  subperitonaeal  extravasations,  pin-head  in  size,  were  discovered  on 
the  posterior  surface  of  the  fundus  of  the  stomach.  The  abdominal  wound 
was  closed  with  silver  wire;  mattress  sutures  for  muscle  and  fascia,  and  a 
continuous  buried  suture  for  the  skin.  The  patient  was  infused  with  salt 
solution  immediately  after  the  operation. 

March  16th. — Pulse  ranged  from  100  to  160;  temperature  from  100.5  to 
104.9.  Intense  thirst;  mind  perfectly  clear;  great  tenderness  on  palpation. 
Abdomen  not  distended.  Patient  is  flushed  and  slightly  cyanotic. 

March  18th. — Patient  is  still  flushed,  with  a  distinct  suggestion  of  cyano- 
sis ;  but  neither  pulse  nor  temperature  evidence  infection. 

March  20th. — General  condition  good.  Abdomen  not  distended.  Patient 
still  flushed.  Yesterday  patient  passed  a  large  quantity  of  coffee-ground 
material.   He  appears  to  be  perfectly  comfortable. 

March  21st. — Patient  has  some  cough  and  complains  of  pain  in  wound 
on  coughing.  Binder  removed  and  dressings  replaced.  Wound  reported  as 
dry  and  looking  well.  Abdomen  not  sensitive  to  pressure. 

March  22d. — Patient  obtained,  surreptitiously,  some  bread,  coffee  and 
water  from  other  patients.  Comfortable  all  day,  but  about  9  p.  m.  began  to 
complain  of  abdominal  pain.  Wound  reported  healed  per  primam.  Abdomen 
slightly  distended. 

March  23d. — Patient's  cough  continues.  He  complains  of  pain  in  the 
wound  on  coughing.  Condition  good.  Patient  has  no  abdominal  symptoms. 
The  wound,  which  had  apparently  healed  per  primam,  has  broken  down 
throughout  its  whole  length  and  depth.  The  recti  muscles,  so  far  as  exposed 
during  the  operation,  are  covered  with  a  necrotic  film.  In  places  there  is 
considerable  sloughing  of  the  tissues.  Patient's  cyanotic  flush  has 
disappeared. 

March  24th. — About  12.30  patient  began  to  complain  of  pain  in  the 
wound.  On  investigation  the  wound  was  found  to  be  widely  open;  out  of 
its  lower  angle  there  protruded  a  knuckle  of  bowel.  The  bowel  was  immedi- 


SURGERY  OF  FOREIGN  BODIES  127 

ately  replaced  and  retained  by  gauze  packing.  Patient's  general  condition 
excellent.   No  elevation  of  temperature  and  no  signs  of  general  peritonitis. 

April  J^th. — Patient  is  receiving  soft  diet — eggs,  milk,  toast,  etc.  All 
packing  has  been  removed  from  the  wound.  In  the  lower  angle  of  the 
wound  is  still  to  be  seen  a  small  knuckle  of  gut  covered  with  granulations 
and  adherent  to  the  parietal  peritonaeum. 

April  loth. — Patient  is  well.  He  has  a  good  appetite  and  is  permitted 
to  eat  what  he  fancies.  The  wound  is  reduced  to  a  narrow  granulating  sore. 
His  abdomen  is  no  longer  sensitive  to  pressure.  Xo  foreign  bodies  have  been 
passed  per  anum  since  the  operation. 

Articles  swallowed : 

20  pieces  of  small  dog-chain 460  cm. 

1  piece  of  large  dog-chain 29    " 

4  watch  chains  31     " 

1  brass  chain 59    " 

2  pieces  of  chain 15    " 

28  594  cm. 

10  horseshoe  nails. 

54  wire  nails  (16  of  these  7£  cm.  long). 
35  ordinary  nails  (8  of  these  6  cm.  long). 


8  screws  (2^-3  cm.). 

2  screw  eyes. 

7  knife  blades. 

1  knife  handle. 
50  tacks. 
12  pins. 

1  piece  of  tin. 

81 

208  articles  and  74  grms.  of  broken  glass.  See  Plates  VI,  VII,  and  VTII. 

In  a  recent  article  by  Hecht  in  the  "Wien.  med.  Woch.,2  we  read :  "  As  I 
find  from  consulting  the  literature,  gastrotomy,  even  in  the  preantiseptic 
and  preaseptic  times,  was  an  operation  comparatively  free  from  danger." 
I  have  found  only  four  authentic  cases  of  gastrotomy  for  foreign  bodies  in 
preantiseptic  times  in  which  the  stomach  was  not,  at  the  time  of  the  opera- 
tion, adherent  to  the  parietal  peritonaeum.  One  of  these  cases  died  on  the 
third  day  after  the  operation;  in  two  the  wound  of  the  stomach  was  very 
small  and  not  even  stitched,  and  in  the  fourth  case  "  the  threatened  peri- 
tonaeal  symptoms  were  conquered  by  collodionated  cuirass,  compression  and 
champagne  frappe."    One  could  not,  fortified  only  with  the  knowledge  of 

1  Wien.  med.  Woch.,  1898,  Bd.  xi,  Xo.  46,  S.  1045. 


128  SURGERY  OF  FOREIGN  BODIES 

these  cases,  proceed,  with  great  confidence  to  do  a  gastrotomy  for  the  re- 
moval of  foreign  bodies. 

In  1880  Poulet 8  wrote  :  "  The  operation  of  gastrotomy  is  hardly  accepted 
by  all  surgeons,  and  the  small  number  of  cases  which  the  literature  contains 
testify  to  the  scant  sympathy  it  has  met  with  for  centuries,  and  to  the  rarity 
of  its  indications.  Gastrotomy  is,  nevertheless,  a  very  old  measure,  since  it 
is  found  in  the  writings  of  authors  who  lived  before  the  reign  of  Louis  XIV. 
One  of  these  cases  quoted  by  Hevin  bears  the  date  of  1636;  that  of  Crollius 
occurred  in  1602 ;  but  since  that  period,  despite  the  thousands  of  cases  of 
foreign  bodies  which  have  been  accumulated,  there  are  not  more  than  20 
cases  of  gastrotomy." 

Crede  *  in  1886  collected  26  cases,  but  in  nine  of  these  the  stomach  was 
at  the  time  of  operation  adherent  to  the  abdominal  wall,  and  in  seven  it  is 
not  stated  in  the  unsatisfactory  reports  of  the  operators  whether  the 
stomach  was  adherent  to  the  wall  of  the  abdomen  or  not;  in  two  of  the 
seven  badly  reported  cases,  even  the  result  is  not  given.  Until  1886,  there- 
fore, we  find  collected  only  ten  cases  in  which  the  stomach  was  not  adherent 
to  the  parietal  peritonaeum  when  it  was  opened  for  the  removal  of  a  foreign 
body.  Two  of  the  ten  died.  Only  one  foreign  body  was  removed  from  each 
stomach  in  the  remaining  eight  cases;  in  all,  1  table  knife,  1  leaden  bar, 
1  fork,  1  broken  coin-catcher,  2  hair  balls,  and  2  sets  of  false  teeth.  Foreign 
bodies  are  swallowed  most  often  by  the  insane  and  by  jugglers,  yet  among 
the  eight  cases  prior  to  1886  which  recovered  from  gastrotomy,  there  was, 
I  observe,  not  an  insane  person  nor  a  juggler;  but  of  the  two  gastrotomized 
patients  who  died  from  the  operation,  one  was  insane  and  the  other  a  pro- 
fessional sword-swallower. 

The  insane  patient,8  a  woman,  aged  32  years,  had  swallowed  a  silver  spoon 
21  cm.  long;  the  juggler,6  a  youth  aged  19  years,  a  piece  of  sword  blade  27 
cm.  long  and  2  cm.  broad.  Both  of  these  cases  were  evidently  in  very  bad 
condition  when  operated  upon. 

Insane  people  swallow  foreign  bodies  usually  with  suicidal  intent;  and 
only  when  their  suffering  is  more  than  they  can  bear  do  they  confess  what 
they  have  done.  Even  then  they  are  often  disbelieved,  and  so  the  operation 
is  postponed  and  the  chances  for  recovery  lessened.  Jugglers,  too,  have  con- 
tributed more  than  their  proportion  to  the  mortality  roll.  This  is  partly 
due  to  the  fact  that  the  very  large  objects  (i.  e.,  pieces  of  sword  blade)  and 
objects  in  large  quantities  have  been  ingested  principally  by  men  of  this 

3  Poulet,  Foreign  Bodies  in  Surgery,  Wm.  Wood  &  Co.,  N.  Y.,  18S0. 

4  Crede,  Arch,  f .  klin.  Chirurgie,  Bd.  xxxiii,  Heft  3,  S.  574. 
6  Case  of  Tilanus  in  Leyden,  1848. 

8  Case  of  Gussenbauer  in  Prag,  1883. 


PLATE   VI 


SURGERY  OF  FOREIGN  BODIES  129 

class.  They,  too,  are  disposed  to  conceal  their  suffering,  and  continue  their 
performances,  giving  five  or  six  daily,  when  they  know  that  their  distress  is 
caused  by  the  bodies  which  they  have  swallowed. 

As  I  have  said,  Crede  in  1886  furnished  us  with  a  very  carefully  prepared 
table  of  the  cases  to  date ;  and  the  same  year,  in  Maurice  Richardson's  most 
admirable  contribution,1  we  find  several  additional  cases  collected.  Then 
Fricker,8  in  1887,  tabulates  27  cases  operated  upon  since  Crede's  publication, 
and  contributing  a  very  remarkable  case  of  his  own,  brings  the  total  number 
of  gastrotomies  for  foreign  bodies  in  the  stomach  and  oesophagus  up  to  54. 
Fricker's  table  is  a  full  one,  giving  the  principal  facts  in  each  case.  A  year 
later,  Meisenbach,"  on  the  lines  laid  down  by  Fricker,  gives  all  the  cases  to 
date;  adding  five  cases,  including  a  creditable  one  of  his  own,  he  makes  a 
total  of  59.  In  November,  1898,  Hecht10  contributes  a  case  of  his  own  and 
two  others,  and  appends  the  bibliography  of  the  subject.  In  the  62  cases 
there  were  only  11  deaths,  17.7  per  cent.  Hecht  attributes  to  peritonitis  only 
two  of  these.  It  is  my  opinion  that  peritonitis  was  at  least  present  in  four 
of  the  fatal  cases,  and  would  surely  have  supervened  in  one  of  the  two  cases 
which  died  of  shock,  and  probably  in  the  other. 

In  most  instances  only  one  foreign  body  has  been  present,  but  in  six  cases 
many  articles  were  extracted  from  the  stomach.  Three  of  the  six  cases  died, 
two  of  shock  within  four  hours,  and  one  within  forty-eight  hours.  Eleven 
pounds  and  nine  ounces  was  the  total  weight  of  the  articles  removed  from 
one  of  the  fatal  cases.  Of  the  three  that  lived,  Mayo  Robson's  u  furnished 
the  greatest  number  of  foreign  bodies,  viz.,  42  cast-iron  garden  nails  If 
inches  long;  93  brass  and  tin  tacks  from  \  to  1  inch  long;  12  large  nails, 
some  brass-headed;  3  collar  studs,  one  safety-pin,  and  one  sewing  needle. 
During  the  22  days  following  the  operation  there  passed,  per  anum,  em- 
bedded in  hard  faecal  matter,  thirty  garden  nails,  a  piece  of  needle,  one  stud, 
eight  tacks  and  a  pen.  This  patient  of  Mr.  Robson's  was  only  ten  years  old, 
said  to  be  an  intelligent  girl  who  apparently  could  not  control  her  morbid 
appetite,  for  after  her  recovery  she  continued  to  swallow  articles  which  she 
could  not  digest. 

The  second  case  was  also  a  remarkable  one.  A  woman,  during  a  temporary 
attack  of  insanity,  swallowed  the  articles  which  Fricker  "  subsequently  re- 
moved:  1  key,  2  teaspoons,  1  fork,  2  pieces  of  wire,  2  hair-pins,  12  pieces 

7  Richardson,  Boston  Med.  &  Surg.  Jour.,  1886,  vol.  ii,  p.  569. 

8  Fricker,  Deutsche  med.  Wochenschr.,  January,  1897,  S.  56. 

9  Meisenbach,  Journal  Am.  Med.  Assoc,  March,  1898,  p.  513. 

10  Hecht,  Wiener  klin.  Wochenschr.,  November,  1898,  S.  1045. 

11  Mayo  Robson,  Lancet,  1894,  p.  1028. 
"Fricker,  Deutsch.  med.  Woch.,  January  21,  1897. 

10 


130  SURGERY  OF  FOREIGN  BODIES 

of  glass,  1  window-latch,  1  steel  pen,  9  sewing  needles,  1  piece  of  graphite, 
1  shoe  button,  1  crochet  needle,  and  one  grape  seed.  Quite  a  large  abscess  had 
formed,  and  through  it  the  crochet  needle  was  withdrawn;  but  the  other 
bodies  were  removed  through  an  incision  which  Fricker  carried  through 
the  posterior  wall  of  the  abscess  into  the  stomach  and  also  into  the  general 
peritonaeal  cavity;  fortunately  general  peritonitis  did  not  result. 

Meisenbach's 1J  is  the  third  successful  case  of  the  kind.  He  extracted  25 
staples  for  barbed  fence  wire ;  15  one  and  one-half  inch  screws ;  6  two-inch 
horseshoe  nails;  16  two-inch  wire  nails;  30  one  and  one-half  inch  wire  nails; 
16  thirty-two  calibre  cartridges;  5  thirty-eight  calibre  cartridges;  2  pocket- 
knife  blades  (broken) ;  2  inches  of  brass  washstand  chain,  and  2  small 
staples;  total  119  pieces.  Eight  cartridges  passed  after  operation.  There 
was  also  one  ounce  of  comminuted  glass  (electric  light  globe),  making  the 
total  number  of  objects  127,  total  weight,  one  pound. 

That  peritonitis  was  avoided  in  my  case,  notwithstanding  the  facts  that 
the  stomach  could  not  for  a  long  time  be  drawn  out  of  the  abdominal  cavity, 
and  that  the  operation  lasted  so  many  hours,  is  probably  in  part  due  to: 
1.  The  small  openings  into  the  stomach  which  could  be  quite  perfectly 
controlled.  2.  The  employment  of  the  strip  of  linen  which  was  sewed  just 
outside  of  the  edges  of  the  incision  into  the  stomach  wall  to  prevent  the 
escape  into  the  abdomen  of  small  particles  of  glass.  This  is  not  a  theoretical 
danger ;  for  quite  large  bodies  have  been  found  free  in  the  abdominal  cavity 
which  could  only  have  escaped  through  the  gastrotomy  wound.  3.  The 
great  care  exercised  and  the  large  amount  of  gauze  used  to  prevent  soiling 
of  the  abdominal  contents.  4.  Postponing  a  second  bimanual  examination 
of  the  stomach  until  the  first  incision  into  the  stomach  had  been  sutured, 
until  a  fresh  toilet  of  the  abdomen  had  been  made,  and  until  the  hands  of 
the  operator  and  assistants  had  been  disinfected.  5.  The  very  thorough 
suture  of  the  stomach  wounds. 

Suture  of  the  stomach. — The  stomach  wound  should  be  most  carefully 
sutured,  and  unless  some  contraindication  exists  the  stomach  should  be 
dropped  back  into  its  normal  position.  With  a  running  stitch  through  the 
mucosa,  close  off  the  stomach  cavity  so  that  the  parts  no  longer  soiled  by 
stomach  contents  may  be  carefully  cleansed  before  the  next  row  of  sutures 
is  taken.  Catgut  may  be  used  for  this  suture  of  the  mucosa ;  next  a  row  of 
mattress  sutures  of  fine  silk;  each  stitch  of  this  row  should  enter  the  sub- 
mucosa  but  not  the  mucosa.  A  third  row  of  stitches  is  important  as  a  safe- 
guard against  a  possible  perforation  of  the  mucosa  by  one  of  the  stitches  of 
the  second  row.    I  have,  within  a  year,  produced  a  fatal  peritonitis  by  a 

"  Meisenbach,  loc.  cit. 


SURGEKY  OF  FOKEIGN  BODIES  131 

single  stitch  which  entered  the  lumen  of  the  stomach.  The  stitches  of  the 
third  row  should  include  only  the  muscular  coats  of  the  intestine.  It  is, 
as  I  have  frequently  pointed  out,  incorrect  to  speak  of  a  suture  of  the  peri- 
tonaeal  coat,  for  even  if  the  peritonaeum  were  not  destroyed  by  the  manipula- 
tion, it  is  too  thin  to  play  any  part  whatever  in  the  suture  of  the  intestinal 
wall;  and  twice,  recently,  I  have  observed  that  the  wall  of  the  intestine, 
although  deprived  of  its  peritonaeum,  can  dispose  of  microorganisms  viru- 
lent enough  to  produce  an  acute  toxaemia  and  extensive  superficial  necrosis 
of  the  muscles  and  fat  of  the  abdominal  wound.  In  the  case  which  we  are 
considering,  it  is  possible  that  the  gastric  juice  lowered  the  resistance  of  the 
tissues  which  succumbed  so  rapidly  to  the  infection  of  the  abdominal  wound. 


SURGICAL  TREATMENT  OF 
TUBERCULOSIS 


CASES  OF  PARTIAL  RESECTION  OF  THE  ELBOW  AND 

SHOULDER    FOR   TUBERCULOSIS,    AND    OF 

THE  ANKLE   FOR  TRAUMATISM1 

Case  I. — Elbow. — A  man,  aged  thirty-six,  believed  that  a  brother  had 
died  of  consumption.  His  family  history  was  otherwise  good.  About  two 
years  ago  pain,  spontaneous  and  insidious,  developed  in  the  right  elbow, 
but  until  July,  1884,  the  patient's  suffering  had  been  inconsiderable.  His 
sleep  was  little  disturbed,  and  moderate  movements  of  the  affected  joint  did 
not  cause  pain.  On  his  admission,  July  22,  1884,  there  was  consolidation 
at  the  apices  of  both  lungs.  The  specific  gravity  of  the  urine  was  1028,  and 
it  contained  oxalate  of  lime.  There  was  a  spindle-shaped  enlargement  of 
the  right  elbow  joint,  with  fluctuating  swellings  to  the  outer  side  of  and 
behind  both  condyles  of  the  humerus.  Flexion,  possible  only  to  less  than  a 
right  angle,  was  painful.  The  inner  swelling  was  incised  and  about  one 
ounce  of  cheesy  pus  was  removed.  September  3d,  the  patient's  elbow  having 
for  several  weeks  annoyed  him  greatly,  injections  of  iodoform  ointment  were 
made  through  a  fistulous  tract  into  the  joint,  and  contributed  at  first  to  his 
comfort.  Anodynes,  even  in  large  doses,  gave  little  relief.  There  was  much 
redness  about  the  joint,  and  the  slightest  motion  caused  great  pain. 

Ether  having  been  given,  Esmarch's  bandage  was  applied,  and  as  strict 
antiseptic  precautions  as  practicable  were  observed.  A  longitudinal  incision 
was  made,  eight  inches  in  length,  parallel  to  and  just  to  the  inner  side  of 
the  inner  border  of  the  olecranon.  Then  a  transverse  incision  was  made, 
at  right  angles  to  the  first  one,  outward  to  the  plane  of  the  radius,  opening 
the  joint  and  dividing  the  triceps  muscle  close  to  its  insertion  into  the  upper 
border  of  the  olecranon  process.  A  short  longitudinal  incision  was  then 
made  at  right  angles  to  the  second  incision,  and  parallel  to  the  outer  border 
of  the  olecranon,  to  the  neck  of  the  radius.  Dr.  Halsted  preferred  dividing 
the  triceps  to  sawing  through  the  olecranon,  as  proposed  and  practised  by 
Brans,  and  practised  by  Mosetig  Moorhof  and  others,  and  by  Dr.  Stimson  in 
the  case  just  presented  by  him,  because  it  was  simpler  in  the  first  act,  viz., 
opening  the  joint,  and  in  the  subsequent  acts,  should  it  prove  necessary,  as  it 
almost  invariably  must,  to  remove  the  articular  surface  of  the  olecranon.  The 
joint  then  being  still  more  thoroughly  exposed  by  liberating  the  sides  of  the 
olecranon  from  the  triceps  and  anconeus  attachments,  all  the  articular  sur- 
faces were  found  to  be  more  or  less  involved  in  the  disease,  which  was  dis- 
tinctly tuberculous  with,  fortunately,  sclerotic  confines.  The  articular 
surfaces  of  the  humerus,  of  the  head  of  the  radius,  and  of  both  sigmoid 
cavities  were  sawn  off,  also  the  upper  surface  of  the  olecranon.    Thus  a 

1  Presented  at  the  New  York  Surgical  Society,  November  11,  1884. 

N.  York  M.  J.,  1884,  xl,  619-620. 

Also:   Med.  News,  Phila.,  1884,  xlv,  662-663. 

135 


136  SURGICAL  TUBERCULOSIS 

rectangular  replaced  the  sigmoid  cavity  somewhat  as  figured  in  Leinhart's 
"  Operationslehre."  The  capsule  and  articular  ligament  were  completely- 
dissected  out  and  the  walls  of  the  sinus  scraped  with  a  Volkmann's  spoon. 
The  end  of  the  humerus  was  sewed  with  catgut  into  the  step  made  in  the 
olecranon,  and  the  space  necessarily  left  between  the  humerus  and  the  radius 
was  obliterated  by  turning  into  it  the  divided  triceps  and  anconeus  muscles, 
which  were  retained  by  several  "  Einstiilpungsnahte."  Other  small  dead 
spaces  were  obliterated  by  quilted  sutures.  Wound  was  closed  by  the  furrier's 
suture,  and  three  short  drainage  tubes  were  introduced.  The  dressing  was 
applied  previous  to  the  removal  of  Esmarch's  elastic  bandage,  and  the  limb, 
flexed  to  about  45°,  was  preserved  from  constriction  by  the  introduction, 
in  the  dressing,  of  narrow  strips  of  wood  to  distribute  the  pressure  made  by 
the  tightly  applied  bandage.  The  arm  was,  of  course,  maintained  elevated 
for  about  thirty-six  hours. 

September  6th. — The  dressing  was  changed;  the  edges  were  perfectly 
united;  there  were  no  signs  of  inflammation. 

September  15th. — Redressed.   No  pus.   Rectangular  splint  applied. 

September  26th. — A  small  subcutaneous  abscess  in  the  cubitus  opened, 
apparently  having  no  connection  with  the  joint. 

The  patient,  as  presented,  seemed  to  have  a  perfectly  healed  joint.  There 
still  remained  in  the  cubitus  the  mouth  of  a  subcutaneous  fistula,  about  half 
an  inch  in  length,  which  did  not,  apparently,  lead  toward  bone.  Although 
it  was  but  six  weeks  since  the  operation,  the  patient  could  flex  and  extend 
the  elbow  moderately  and  without  pain.  Dr.  Halsted  advocated  partial  as 
opposed  to  so-called  typical  resections  of  the  elbow  joint  for  tuberculosis. 

Case  II. — Shoulder. — I.  H.,  male,  aged  fifteen  j^ears.  No  tuberculosis 
heredity  ascertained.  All  the  members  of  his  immediate  family  alive  and 
healthy.  About  the  middle  of  April,  1884,  he  wrenched  his  left  arm  while 
lifting  down  a  coal-scuttle.  He  felt  pain  immediately  in  the  left  shoulder 
joint,  severe  enough  to  prevent  sleep  for  three  nights.  On  the  fourth  day 
the  pain  had  subsided,  except  on  motion.  A  few  days  later  he  applied  at 
the  Roosevelt  Hospital  Out-Patient  Department  for  relief.  The  muscles 
about  the  joint  were  then  much  atrophied.  The  head  of  the  humerus  on 
the  affected  side  appeared  smaller  than  on  the  sound  side.  The  joint  was 
not  thickened  at  any  part,  but  was  fixed  by  muscular  action.  Passive  motion 
and  palpation  of  joint  were  painful.  There  were  no  points  of  special  ten- 
derness. A  plaster  of  Paris  splint  was  applied,  and  on  August  20th,  when 
the  splint  was  removed,  there  had  been  no  pain  whatever  since  its  applica- 
tion. There  was  a  fluctuating  tumor  of  about  the  size  of  a  pigeon's  egg  at 
the  back  of  the  joint,  under  the  deltoid  muscle.  The  skin  over  it  was  normal. 
August  26th,  about  one  drachm  of  flocculent  pus  was  withdrawn  from  the 
abscess  with  a  Pravaz's  syringe,  and  iodoform  ointment  (iodoform,  one  part; 
almond  oil,  two  parts)  was  injected  into  the  abscess  cavity.  Examination  of 
the  pus  by  Dr.  R.  J.  Hall  revealed,  from  eight  cover-glasses,  five  tubercle 
bacilli. 

August  27th. — Patient  was  confident  that  he  had  been  benefited  by  the 
iodoform  injection,  and  unwillingly  allowed  a  repetition  of  the  aspiration 
and  injection  of  the  cavity,  which  had  more  than  attained  its  former  size. 

September  IJfth. — Condition  essentially  unaltered. 


STJEGICAL  TUBERCULOSIS  137 

September  16th. — Arthrotomy  was  performed  by  a  posterior  incision 
through  the  abscess,  leading  directly  into  the  joint,  which  was  distended 
with  pus.  The  much-diseased  head  of  the  humerus  was  sawn  off  at  the 
surgical  neck;  the  glenoid  cavity  and  capsule,  also  extensively  involved  in 
the  tuberculous  process,  were  scraped  with  a  sharp  spoon.  The  furrier's 
suture  was  used,  and  a  short  rubber  drain  was  inserted  at  the  lower  angle 
of  the  wound. 

September  80th  (two  weeks  after  the  operation). — Original  dressing 
removed.  Wound  healed,  without  pus,  to  the  drainage  tube.  Tube  removed. 

October  10th. — Second  dressing. 

November  1st. — Wound  entirely  healed.  Free  passive  motion  does  not 
cause  pain;  active  movements  inconsiderable.  Electricity  applied  to  the 
deltoid. 

On  presenting  the  patient,  whom  he  had  not  seen  for  one  week,  Dr.  Halsted 
discovered  a  small  fistulous  tract  at  the  lower  angle  of  the  wound. 

The  interesting  features  in  the  case  were  its  traumatic  origin,  the  imme- 
diate atrophy  of  the  deltoid  muscle,  the  failure  of  iodoform  injections,  the 
rapid  healing  of  the  wound,  and  the  early  partial  restoration  of  function. 

Case  III. — Ankle. — C.  L.,  aged  twenty-seven  years,  was  admitted  to 
Roosevelt  Hospital  October  17,  1883.  Just  before  admission  he  had  been 
thrown  from  a  horse,  and,  as  he  fell  on  his  feet,  his  right  foot  turned  under 
him.  The  tibia  and  fibula  protruded  from  an  extensive  wound  on  the  outer 
side  of  the  ankle,  the  foot  being  strongly  supinated.  Both  malleoli  were 
broken  off  and  adherent  to  the  dislocated  foot.  The  patient  was  etherized, 
and  the  malleoli  were  removed,  together  with  two  inches  or  more  of  the 
lower  ends  of  the  splintered  upper  fragments  of  the  tibia  and  fibula.  The 
furrier's  suture  was  used.  A  rubber  drainage-tube  was  passed  through  the 
joint. 

October  30th. — Wound  dressed  for  the  first  time.  Complete  union  along 
the  lines  of  suture. 

November  7th. — Second  dressing;  superficial  ulcers  where  the  drainage- 
tube  had  been. 

December  lJfth. — Patient  walks  with  crutches.  On  presentation,  he 
walked  easily  with  lateral  brace.  He  could  flex  and  extend  the  ankle  quite 
as  much  as,  if  not  more  than,  on  the  sound  side,  notwithstanding  the  short- 
ened leg  bones. 

Corrosive-sublimate  solution,  1  to  1,000,  was  used  as  the  irrigation  fluid, 
and  iodof  ormed  gauze  as  the  dressing,  in  the  three  cases.  The  wounds  healed 
in  all  primarily. 


A  TUBERCULOUS  KXEE-JOIXT  l 

Our  first  case  is  that  of  a  tuberculous  knee-joint  which  we  exsected.  The 
patient  is  a  woman  of  40  years  of  age,  and  her  trouble  commenced  a  year 
and  a  half  ago.  When  she  was  admitted  to  the  hospital  she  was  suffering 
greatly  and  wished  to  haTe  the  knee  operated  upon.  The  disease  was  quite 
advanced,  the  entire  capsule  being  involved.  There  were  no  foci  of  disease 
in  the  bone,  so  that  we  could  in  this  instance  do  an  operation  which  we  do 
in  all  cases  of  ankylosis  from  any  other  cause  than  tuberculosis.  Instead  of 
-g  a  wedge-shaped  piece  as  is  ordinarily  done,  and  shortening  the  leg 
a  good  deaL  we  simply  take  off  the  head  of  the  tibia  and  make  in  it  a 

In  this  way  we  do  away  with  the  necessity  of  sutures ;  the  bones  fit  ac- 
curately into  each  other,  and  there  is  no  tendency  to  lateral  displacement. 
There  is  a  tendency  to  flex  backwards,  but  it  is  easy  to  apply  extension  in 
such  a  away  that  stitches  are  practically  superfluous.  The  operation  was 
done  nineteen  days  ago.  Of  course  it  is  too  early  for  ankylosis,  but  it  is  quite 
firm  already.  This  is  the  first  time  we  have  looked  at  the  wound  since  the 
operation.  The  result  is  very  good. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Sodetv,  Baltimore,  April  3, 
1893. 
Johns  Hopkins  Hosp.  BuIL,  Bait..  1S93.  : 


13S 


EXCISION  OF  ONE-HALF  (ANTERIOR)  OF  THE  HEAD.  NECK 

AND  UPPER  PORTION  OF  THE  TROCHANTER  OF  THE 

RIGHT  FEMUR  BY  FRONTAL  SECTION  FOR 

TUBERCULOSIS  OF  THE  HIP-JOINT  1 

To  indicate  what  we  mar  hope  for  as  a  final  result  in  certain  cases  of 
hip-joint  disease,  even  when  a  considerable  portion  of  the  head  of  the  femur 
has  been  removed,  and  in  support  of  what  Dr.  Bloodgood  has  said,  I  will 
refer  very  briefly  to  a  case  which  I  intend  very  soon  to  report  in  full  with 
other  interesting  hip-joint  cases.  The  patient,  a  boy,  thirteen  years  old  on 
admission,  had  an  acute  osteomyelitis  in  1895,  at  the  age  of  eleven,  which 
involved  the  entire  diaphysis  of  the  right  femur.  Eleven  months  he  spent 
in  bed,  and  for  seven  months  could  not  lie  on  the  affected  side.  After  walk- 
ing about  with  a  cane  and  without  much  pain  for  more  than  a  month  he  had 
to  take  to  his  bed  again  for  a  week  during  a  second  acute  attack  of  pain  in 
the  same  bone.  Two  or  three  months  later  two  abscesses  appeared,  one 
behind  the  knee  and  one  internal  to  the  trochanter.  The  boy  was  thence- 
forth for  nearly  a  year  quite  comfortable  and  considered  himself  sufficiently 
well,  until  the  first  of  November,  1897,  when  he  was  hit  in  the  right  groin  by 
a  wagon-pole.  He  suffered  greatly  from  this  blow,  and  the  following  morn- 
ing could  not  flex  his  thigh.  Two  weeks  later,  November  19,  1897,  he  was 
brought  to  us  by  his  physician,  who  stated  that  for  several  days  he  had  been 
having  very  high  fever  with  daily  intermissions.  The  boy  was  emaciated; 
his  expression  anxious  and  indicative  of  suffering.  He  lay  on  his  back ;  the 
right  thigh  was  abducted,  rotated  outwards  and  slightly  flexed :  the  groove 
in  the  right  groin  was  obliterated  and  there  was  an  appreciable  fulness  over 
the  head  and  neck  of  the  femur.  Pressure  over  the  joint  and  all  attempts  to 
move  the  head  of  the  femur  caused  pain.  About  the  level  of  the  top  of  the 
trochanter  of  the  right  femur,  but  internal  and  anterior  to  it,  was  a  sinus 
from  which  pus  escaped.  Behind  the  inner  hamstring  tendons  was  the 
orifice  of  a  second  sinus  discharging  more  pus  than  the  other.  The  femur 
was  much  enlarged,  and  the  soft  parts  of  the  thigh  were  swollen.  An  in- 
volucrum  had  evidently  replaced  the  entire  diaphysis.    A  probe  in  the 

1  Remarks  in  discussion  of  Dr.  Joseph  C.  Bloodgoods  paper.   "  Early  exploratory 
operations  in  tuberculosis  of  the  hip."  The  Johns  Hopkins  Hospital  Medical  S: 
Baltimore,  May  8,  1889. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1900,  xi.  19. 

139 


140  TUBEKCULOSIS  OF  THE  HIP-JOIXT 

popliteal  sinus  touched  rough  bone.   The  measurements,  which  developed  a 
fact  or  two  of  interest,  I  will  give  at  another  time. 

First  Operation.  Xouember  2!+,  1S97. — Excision  of  one-half  (anterior)  of 
the  head,  neck  and  upper  portion  of  trochanter  of  the  right  femur  by 
frontal  section. 

There  was  a  small  abscess  containing  only  a  few  drachms  of  pus  just 
below  and  in  front  of  the  capsule  of  the  hip-joint,  which  communicated 
with  this  joint.  The  wall  of  the  abscess  was  carefully  excised.  Having  made 
the  frontal  section  of  the  trochanter,  neck  and  head  of  femur,  the  extent 
of  the  disease  in  these  parts  could  be  accurately  determined.  The  upper 
end  of  the  soft  sequestrum  was  cut  off.  The  disease  had  involved  the  neck 
and  head  and  had  finally,  perhaps  just  after  the  blow  from  the  pole,  infected 
the  hip-joint.  By  some  oversight  no  drawing  was  made  of  the  lesions  in  the 
head,  neck  and  trochanter.  Xowhere  were  there  signs  of  active  bone  disease ; 
there  was  a  little  sequestrum  near  the  top  of  the  trochanter,  and  a  little,  very 
slender  bit  of  sequestrated  bone  in  the  neck ;  the  shape  of  the  head  and  of 
the  neck  was  not  altered  by  the  disease :  the  head  of  the  bone  had  lost  some 
of  its  cartilage,  and  granulations  were  growing  from  the  denuded  parts. 
The  infection  of  the  joint  was  probably  recent,  and  it  could  be  demonstrated 
how  this  might  have  taken  place.  It  was  not  contemplated  at  the  outset  to 
do  more  at  the  first  operation  than  to  relieve  the  trouble  about  the  hip-joint, 
for  the  patient's  condition  contraindicated  an  extensive  operation.  The 
patient  recovered  promptly  from  this  and  from  two  subsequent  operations 
upon  the  middle  and  lower  thigh.  As  you  may  see  in  the  photographs,  the 
boy  can  extend  his  thigh  perfectly,  and  can  flex  it  to  nearly  a  right  angle. 
He  walks  without  a  cane  and  says  that  he  finds  the  right  thigh  as  useful  as 
the  left.  The  operated  thigh  is  from  1  to  1.5  cm.  longer  than  the  other; 
and  there  are  2  cm.  of  apparent  lengthening  on  the  right  or  operated  side. 
This  apparent  lengthening  is  due  in  part  to  abduction  and  will  undoubtedly 
disappear. 

This  case  sheds  a  new  light  upon  the  surgery  of  the  hip-joint,  proving  as 
it  does  that  not  only  a  useful  but  functionally  an  almost  perfect  joiDt  may 
be  obtained  even  when  one-half  of  the  head  and  neck  of  the  femur  have  been 
removed  by,  approximately,  a  frontal  section.1  We  may,  therefore,  attack 
tuberculous  cases  in  the  early  stages  in  some  such  conservative  way,  taking 
a  fine  and  very  thin  slice  from  the  anterior  surface  of  the  neck  or  head,  or 
trochanter,  or  from  all,  and  having  located  the  disease,  excise  only  as  much 
as  may  be  necessary.  The  acetabulum  can  be  explored  in  a  similar  manner. 
If  the  disease  is  operated  upon  early  it  would  probably  rarely  if  ever  be 
necessary  to  remove  the  whole  head  of  the  femur;  and  we  may  find  that 
having  removed  a  part  of  the  disease  the  remainder,  as  in  tuberculous  peri- 
tonitis, may  take  care  of  itself  the  better  for  having  been  interfered  with 
and  assisted. 

'Original  procedure  (W.  S.  H.). 


TUBERCULOSIS  OF  THE  HIP-JOINT  141 

The  hip-joint,  a  simple  ball  and  socket  joint,  promises  more  for  these 
conservative  operations  than  any  other  joint;  large  surfaces  covered  with 
cartilage  do  not  lend  themselves  so  readily  to  the  formation  of  strong  ad- 
hesions and  ankylosis  as  the  less  simple  joints;  of  all  the  joints  the  knee  is 
perhaps  the  least  suitable  for  conservative  surgery.  With  its  ligaments  and 
reduplication  of  synovial  membrane,  with  its  libro-cartilages  and  numerous 
recesses  and  pockets  it  furnishes  conditions  well  suited  to  the  propagation 
of  the  tubercle  bacillus:  and  when  the  crucial  and  lateral  ligaments  have 
been  much  weakened  by  the  disease,  an  ankylosed  joint  is  usually  more  ser- 
viceable and  more  comfortable  than  one  in  which  motion  has  been  secured. 


EESULTS  OF  THE  OPEN-AIR  TREATMENT  OF  SURGICAL 
TUBERCULOSIS  ■ 

Planned  and  partly  written  more  than  ten  years  ago,  this  paper  was  not 
completed  until  last  autumn  (1904),  when  the  private  clinical  material 
seemed  large  enough  and  to  have  been  observed  long  enough  to  make  the 
report  convincing.  Even  now  my  list  of  private  cases  of  surgical  tuberculosis 
is  not  a  long  one.  It  is  not  to  be  expected  that  people  accustomed  to  luxury, 
and,  particularly,  when  in  poor  health,  should  relish  the  prospect  of  a  winter 
in  a  boarding-house  at  Saranac.  I  am,  therefore,  under  great  obligations  to 
the  patients  who  have  so  courageously  and  with  such  implicit  trust  yielded 
to  my  very  earnest  solicitations  to  exile  themselves  for  a  winter  at  least. 
Today  we  cannot  well  realize  the  amount  of  faith  which  this  required  15 
years  ago,  when  not  a  single  precedent  could  be  cited,  when  one  could  indi- 
cate no  case  of  surgical  tuberculosis  which  had  been  treated  in  even  a  most 
desultory  out-of-door  fashion,  and  when  patients,  encouraged  to  believe  that 
they  would  get  well  if  they  remained  at  home  and  indoors,  asked  me  to 
explain  how  mountain  air,  inhaled  ever  so  deeply,  could  reach  the  bone. 

The  sanatorium  of  Dr.  Trudeau,  at  Saranac  Lake,  had  been  in  existence 
only  about  four  years  when,  in  1889,  soon  after  my  call  to  The  Johns 
Hopkins  University,  I  first  met  him,  and  one  afternoon  listened  for  hours, 
charmed  by  the  story  of  his  life,  his  work,  and  his  dreams  for  the  future. 
He  eagerly  welcomed  the  suggestion  that  possibly  all  cases  of  tuberculosis, 
irrespective  of  the  situation  of  the  lesion,  might  be  benefited  by  the  treat- 
ment which  he  believed  was  proving  to  be  of  great  value  for  pulmonary 
tuberculosis.  The  milder  the  case,  or,  in  other  words,  the  more  nearly  per- 
fect the  patient's  immunity,  the  greater,  presumably,  was  the  prospect  of 
cure.  Hence,  cases  of  bone  and  lymph-gland  tuberculosis,  which,  under  vari- 
ous names,  had  for  tens  of  centuries  been  regarded  as  more  or  less  curable, 
and  certainly  as  infinitely  less  to  be  dreaded  than  "  consumption,"  seemed 
eminently  proper  ones  for  the  open-air  treatment. 

There  is  abundant  evidence  from  France,  and  especially  from  England, 
as  to  the  genuineness  of  the  cures  of  struma  and  of  rickets  by  the  laying  on 

1  Presented  at  the  First  Annual  Meeting  of  the  National  Association  for  the  Study 
and  Prevention  of  Tuberculosis,  Washington,  D.  C,  May  18-19,  1905. 

Nat.  Ass.  Study  &  Prevent.  Tuberculosis,  Trans.,  N.  Y.,  1906,  i,  281-303.  (Re- 
printed.) 

Also:    Am.  Med.,  Phila.,  1905,  x,  937-946.    (Reprinted.) 
142 


SUEGICAL  TUBERCULOSIS  143 

of  the  King's  hand.  The  practice  can  be  traced  in  England  to  Edward  the 
Confessor  (  +  1066)  and  in  France  to  Phillip  the  First  (  +  1108)  Le  Box 
fe  touche,  Dieu  te  querit.  From  the  official  register  it  appears,  for  example, 
that  90.798  persons  suffering  from  the  "King's  evil,"  were  touched  by 
Charles  II  (1660-1664  and  1669-1682).'  John  Browne,  Chirurgeon  in 
Ordinary  to  his  Majesty,  the  author  of  four  treatises  (1684)  on  the  subject, 
gives  a  figure  even  larger  in  his  Charisma  Basilicon,  or  the  Boyal  Gift  of 
Healing  Strumae,  or  "  King's  Evil,"  Swellings  by  Contact,  or  Imposition 
of  the  Sacred  Hands  of  our  Kings  of  England  and  France,  given  them  at 
their  Inaugurations. 

Shakespeare  refers  to  the  custom  (Macbeth,  Act  IT,  Scene  3) : 

Doctor. — Ay.  sir:  there  are  a  crew  of  wretched  souls 

That  stay  his  cure;  their  malady  convinces 

The  great  assay  of  art:  but,  at  his  touch. 

Such  sanctity  hath  heaven  given  his  hand, 

They  presently  amend. 

*        *        *        * 
MACDtTF. — What's  the  disease  he  means? 
Malcolm. — Tis  called  the  evil; 

A  most  miraculous  work  in  this  good  King; 

Which  often,  since  my  here-remain  in  England, 

I  have  seen  him  do.    How  he  solicits  heaven. 

Himself  best  knows;  but  strangely-visited  people, 

All  swoln  and  ulcerous  pitiful  to  the  eye. 

The  mere  despair  of  surgery,  he  cures; 

Hanging  a  golden  stamp  about  their  necks. 

Put  on  with  holy  prayers:  and  'tis  spoken, 

To  the  succeeding  royalty  he  leaves 

The  healing  benediction. 

The  cost  of  these  golden  stamps  in  certain  years  was  more  than  3000 
pounds,  sterling :  so  great  that  in  Elizabeth's  reign  silver  coins  were  substi- 
tuted for  the  gold.  Many  of  the  best  known  English  surgeons,  Gaddesden, 
Gale,  Clowes,  Bannister,  from  the  thirteenth  to  the  seventeenth  century, 
iffy  to  the  marvelous  results  of  this  practice.1  Is  it  not  very  likely  that 
the  exposure  to  all  weathers,  day  and  night,  the  life  in  the  open,  led  by  the 
afflicted  on  their  long  pilgrimages  to  Norway,  France,  England,  effected  the 
cures  of  the  King's  evil  and  deserved  all  the  glory  enjoyed  by  the  monarchs 
endowed  with  the  miraculous  touch  ? 

Though  the  knowledge  of  opsonins  was  a  little  indefinite  in  the  early 
Adirondack  days,  it  was  evident  that,  in  a  general  way,  improvement  in 

1  Gurlt :  Geschichte  der  Chirurgie. 
'  Gurlt,  1.  c. 


144  OPEN-AIR  TREATMENT 

nutrition,  whatever  that  signifies,  is  responsible  for  the  subsidence  of  the 
disease.  After  my  talk  with  Dr.  Trudeau,  a  year  passed  before  the  patient 
destined  to  be  the  first  to  make  the  true  experiment  in  the  treatment  of 
surgical  tuberculosis  presented  himself.  But  in  the  meantime  we  were 
accumulating  evidence  of  a  less  conclusive  kind  on  the  "  bridge  "  of  The 
Johns  Hopkins  Hospital.  The  open-air  treatment  of  surgical  tuberculosis 
possibly  began  with  the  admission  of  the  first  tuberculous  patient  to  the 
surgical  wards  of  this  hospital.  He  was  wheeled  in  his  bed  to  a  spot  on  the 
roof  of  the  long  corridor.  A  rough  trundle-bed  had  been  constructed  for 
the  purpose  of  transporting  beds  easily  from  the  wards  to  the  bridge  and  to 
the  clinics.4  Although  at  first  the  surgical  beds  on  the  bridge  afforded 
amusement  for  most  except  those  whose  duty  it  was  to  trundle  them,  very 
soon  the  benefit  to  the  patients  was  so  definite  and  evident  that  even  certain 
nontuberculous  patients,  particularly  those  convalescing  from  other  infec- 
tions, were  also  treated  to  fresh  air.  Just  the  other  day,  for  example,  a  child 
about  11,  operated  upon  for  appendicitis,  had  a  septic  postoperative  tem- 
perature, ranging  from  101°  F.  to  106°  F.,  for  nearly  three  months.  Whether 
general  infection  or  an  un  discoverable  local  focus  of  infection  was  responsi- 
ble for  her  temperature  has  never  been  determined.  Her  haemoglobin  sank 
to  25  per  cent.  Finally,  when  her  life  was  almost  despaired  of,  she  was 
transported  to  the  bridge  and,  seemingly  from  that  moment,  her  convales- 
cence and  prompt  recovery  began. 

It  is  a  real  joy  to  patients,  this  life  in  bed  on  the  bridge.  It  relieves  the 
monotony  of  the  confinement,  and  they  discover  that  it  gives  appetite  and 
sleep  and  vigor.  After  a  severe  surgical  operation,  patients,  if  restless  and 
sleepless,  often  find  that  the  day  out-of-doors  in  bed  refreshes  and  soothes 
them  and  insures  a  peaceful  night  and  a  morning  minus  the  headache  inci- 
dent to  an  anodyne.  And  what  a  boon  it  must  be  to  the  typhoid  convales- 
cents, to  those  suffering  from  the  so-called  posttyphoid  septicaemia.  The 
main  rectangular  corridor  is  12  feet  wide  and  more  than  1300  feet  long; 
hence,  the  length  of  the  veranda  or  "  bridge,"  its  roof,  is  about  a  quarter  of 
a  mile.  I  have  intended  for  years  to  ask  the  distinguished  designer  of  the 
hospital,  Dr.  J.  S.  Billings,  if  he  had  in  mind  any  such  possible  use  for 
the  bridge  when  he  planned  it.  This  treatment  of  patients  with  surgical 
tuberculosis  has  been  carried  on  uninterruptedly  for  the  past  16  years;  and 
now,  every  day,  with  few  exceptions,  winter  and  summer,  the  bridge  is 
strewed  with  the  sick. 

*  The  idea  and  the  design  for  this  trundle  we  brought  from  the  great  clinic  of 
Volkmann,  in  Halle,  where  it  was  used  to  transport  beds  from  the  wards  to  the 
amphitheatre,  and  from  ward  to  ward. 


SURGICAL  TUBERCULOSIS  145 

But  it  is  from  my  private  patients  that  I  have  learned  the  almost  incredi- 
ble value  of  the  true  out-of-door  living  in  the  treatment  of  surgical 
tuberculosis. 

I  have  treated  no  patient,  the  hospital  cases  excepted,  who  would  not  or 
could  not  live  out  of  doors  in  the  manner  prescribed. 

There  follows  a  brief  abstract  of  all  the  private  cases,  and,  hereupon,  the 
fuller  histories  of  the  first  four  of  these,  which  latter  were  the  pioneer 
patients,  the  experimental  cases,  and  have  been  under  observation  for  many- 
years.  They  were  also  serious  cases  whose  progress  has  been  watched  with 
unusual  concern  and  satisfaction : 

Case  I. — Pott's  disease  with  sinuses.  Enormous  waxy  liver.  In  bed,  very 
ill,  and  supposed  to  be  dying  when  he  consulted  me  in  1890.  Transported 
in  private  car  to  Saranac  Lake.  Restored  to  fair  health,  married,  father  of 
three  children,  lived  12  years,  died  of  nephritis.    (Fuller  history  follows.) 

Case  II. — Child,  aged  15.  Family  history  of  tuberculosis.  Hip  disease 
a  year  and  a  half.  Large  abscess  in  or  about  joint  February,  1893.  Iodoform 
injections ;  rigorous  out-of-door  treatment  at  home  in  Maryland  and  moun- 
tains of  Pennsylvania  for  seven  years;  then  January,  1900,  to  Adirondacks, 
where,  in  five  weeks,  she  gained  nine  pounds.  On  her  return  she  looked  really 
well,  for  the  first  time  since  my  first  examination.  Brace  and  crutches  were 
discarded,  and  riding,  driving,  walking,  dancing,  and  social  pleasures  were 
freely  indulged  in  with  true  relish  after  the  long,  weary  years  of  life  in  a 
chair  on  the  piazza.  But  day  after  day,  and  night  after  night,  our  patient's 
strength  was  taxed  (1900  and  1901)  and  the  hours  on  the  piazza  became 
fewer  and  fewer,  and  finally  none.  Then,  in  less  than  two  years  from  the 
time  "cured"  (December,  1901),  she  noticed  a  little  swelling  and  stiffness 
above  the  right  wrist,  for  which  she  soon  consulted  me.  Her  general  condi- 
tion was  poor,  almost  bad. 

Diagnosis. — Tuberculosis  of  tendon  sheaths.  At  operation  a  very  active 
and  extensive  process  from  palm  to  upper  third  of  forearm  was  revealed; 
thousands  of  fresh  tubercles  in  sheaths  and  muscles  were  carefully  removed. 
Patient  went  eagerly  and  promptly  after  the  operation  to  Saranac,  where, 
in  the  first  month,  she  gained  16  pounds.  The  winter  was  spent  in  the 
Adirondacks  and  the  summer  in  the  Austrian  Tyrol.  May,  1903.  Patient 
enjoys  perfect  health.  She  walks  with  a  hardly  noticeable  limp.  Flexion 
permitted  to  a  right  angle  at  affected  hip,  although  the  head  of  the  femur 
has  disappeared.  The  slightly  expanded  end  of  neck  occupies  the  aceta- 
bulum. The  function  of  hand  and  wrist  is  perfectly  restored.  Results  like 
this,  very  rare  in  the  past,  will  be  common  in  the  future.  (Fuller  history 
follows. ) 

Case  III. — Mrs. d,  aged  28,  March,  1894.   Sister  died  of  pulmonary 

tuberculosis,  aged  36.  Is  very  delicate  and  neurotic.  Fluid  in  right  knee- 
joint.  Typical  tender  points.  Iodoform  injections,  at  my  suggestion,  by  the 
late  Professor  Dabney,  of  Charlottesville,  Va.  Life  out-of-doors  in  Virginia 
conscientiously  carried  out.  June,  1894,  no  improvement.  Adirondacks 
11 


146  OPEN-AIR  TREATMENT 

urged,  but  not  feasible.  Injections  continued  by  Dr.  Dabney.  October,  1895, 
disease  progressing  rapidly.  Resection  considered.  November  5,  1895, 
patient  presented  herself  in  Baltimore  for  operation.  She  coughed  and  had 
fever.  Examination  of  lungs  revealed  apical  involvement.  Consented  to  go 
to  the  Adirondacks.  Pulmonary  haemorrhage  en  route.  Weight,  86  pounds. 
Normal  weight,  104;  greatest  weight,  112  pounds.  Arrival  at  Saranac,  ex- 
amined promptly  by  Dr.  Trudeau.  His  prognosis  guarded,  but  rather  un- 
favorable. On  subsequent  examinations  it  proved  that  the  disease,  though 
incipient,  was  still  advancing;  prognosis  more  decidedly  unfavorable.  For 
several  months  no  improvement,  then  a  slight  gain,  and  in  August,  1896, 
she  weighed  95  pounds,  a  gain  of  nine  pounds  in  about  nine  months. 
Circumstances  made  Adirondacks  too  difficult.  The  mountains  of  western 
North  Carolina  were  suggested,  but  patient  was  so  much  encouraged  that 
she  returned  to  Virginia.  There  she  slowly  but  surely  lost  ground. 
Eventually,  October,  1897,  she  made  her  home  in  the  North  Carolina  moun- 
tains. The  lesson  learned  at  Saranac  was  of  great  value  here.  She  lived  the 
true,  open-air  life  faithfully. 

In  September,  1898,  I  found  astonishingly  great  improvement  in  the  con- 
dition of  lungs  and  knee,  and  in  a  few  months  discontinued  the  plaster  cast. 
In  May,  1899,  weight  97  pounds.  In  January  and  February,  1900,  she 
visited  in  Virginia  and  lost  much  ground.  Possibly  developed  a  slight 
pleurisy.  Returned  to  North  Carolina  and  gradually  regained  what  was  so 
rapidly  lost.  November,  1900,  knee  still  better.  January,  1901,  motion  in 
knee  returning.  Then  a  second  visit  to  her  home  in  Virginia  again;  and 
promptly,  a  pleurisy;  she  became  so  ill  that  it  was  difficult  to  return  to 
North  Carolina.  January,  1903,  examination.  I  could  hardly  believe  what 
I  saw.  The  right  knee-joint  looked  perfectly  normal,  except  for  a  very 
slight  fulness  on  either  side  of  the  ligamentum  patellae. 

Under  Dr.  Thayer's  care  this  patient  has  gained  more  than  20  pounds 
within  a  few  months.  He  is  unable  to  find  a  trace  of  the  pulmonary  disease 
which  at  one  time  was  so  active  as  seriously  to  menace  her  life.  (Fuller 
history  follows.) 

Case  IV. — Miss 1,  aged  38.    Tuberculous  family  (sister,  uncle  and 

aunt).  Hip- joint  disease ;  initial  stage.  Tuberculin  reaction.  Modified  open- 
air  treatment  in  Pennsylvania  for  eight  months.  Through  misunderstand- 
ing, considerable  exercise  was  taken.  Disease  made  such  definite  progress 
that  I  became  alarmed  and  urgently  advised  Adirondacks.  Immediate  and 
great  improvement  in  general  and  local  condition  at  Saranac  Lake.  Brace 
and  crutches  discarded  three  years  after  first  examination.  Motion  at  hip- 
joint  almost  perfect.  Unless  very  careful  comparisons  with  the  other  hip 
are  made  there  is  no  indication  of  impairment  of  function.  Even  the  ap- 
parent shortening  (adduction)  which  the  brace  could  not  overcome  and 
which  persisted  for  nearly  three  years,  has  vanished.  Only  the  reaction  to 
tuberculin  remains.    (Fuller  history  follows.) 

Case  V. — Miss m,  aged  14.   In  September,  1900,  fell,  striking  right 

hip.  Bruise  over  right  trochanter.  Attended  school  regularly.  Consulted 
me  about  four  months  later  for  limp  and  occasional  pain  in  right  knee. 
Patient  seemed  in  good  health,  but  had  lost  a  little  in  weight  and  perspired 


SUKGICAL  TUBEKCULOSIS  147 

easily.  There  was  about  1.5  cm.  apparent  lengthening  of  the  right  leg,  but 
no  difference  in  circumference  of  thighs  and  legs  on  the  two  sides.  Hardly 
demonstrable  limitation  of  motion  in  any  direction ;  little  if  any  rigidity  of 
the  adductors  of  the  thigh.  Extreme  hip  movements  caused  pain  in  the 
knee  of  the  affected  side.  Tuberculin  was  administered  three  times  at  her 
home.  The  reaction  was  very  slight  but  definite,  becoming  more  pronounced 
as  the  dose  was  increased.  Definite  pain  in  the  hip  itself  was  experienced 
for  the  first  time  a  day  or  two  after  the  exhibition  of  the  third  dose  of 
tuberculin. 

February  13,  1901,  admitted  to  The  Johns  Hopkins  Hospital.  Supplied 
with  brace  and  treated  on  the  "  bridge  "  until  May  13,  1901.  While  in  the 
hospital  she  was  entirely  free  from  pain  except  for  occasional  brief  twinges 
in  hip  and  knee. 

From  the  hospital,  patient  went  to  Atlantic  City  for  a  few  weeks  and 
thence  to  the  Adirondacks  for  the  remainder  of  the  summer.  During  the 
following  winter  it  seemed  so  difficult  to  arrange  for  patient's  departure 
to  the  Adirondacks  that  she  was  permitted  to  live  in  town,  spending  her 
days,  however,  out-of-doors  on  a  balcony.  In  the  spring  she  had  lost  so  much 
in  weight  and  her  general  condition  was  so  unsatisfactory  that  I  almost  in- 
sisted upon  a  change.  Tuberculin  again  administered  was  followed  by  a 
prompt  reaction,  the  temperature  reaching  103°  F.  A  winter  in  the  Adiron- 
dacks completely  restored  our  patient  to  health. 

May,  1905,  two  years  after  the  institution  of  treatment  a  cane  was  sub- 
stituted for  the  brace.  In  a  few  months  the  cane  was  discarded  and  patient 
has  led  the  active  life  of  a  young  society  girl  ever  since.  She  has  no  pain  nor 
limp  and  seems  perfectly  well. 

Case  VI. — Mrs.  J n,  aged  34.  Admitted  October  4,  1902.  Diagnosis, 

sacroiliac  tuberculosis.  Two  years  ago  pleurisy  in  left  side.  No  night  sweats 
and  no  shortness  of  breath. 

Present  illness  began  in  April,  1902.  Patient  felt  slight  twinge  in  back 
on  getting  into  carriage.  Next  day  had  severe  pain  in  region  of  sacroiliac 
synchondrosis.    Since  then  patient  has  suffered  constantly. 

Examination. — Considerably  emaciated.  Gums  pale.  No  tenderness  on 
pressure  over  spines  of  vertebrae.  Over  right  half  of  sacrum  is  a  slight  ful- 
ness and  over  this  some  tenderness.  Tenderness  also  in  sciatic  notch  and 
along  sciatic  nerve.  Little  if  any  tenderness  over  Poupart's  ligament  on 
right  side,  except  on  very  deep  pressure.  In  August,  1902,  in  Virginia, 
patient's  ovaries  and  appendix  were  removed. 

October  16th,  Operation,  Cocaine,  Dr.  Hoisted. — Aspiration  of  tubercu- 
lous abscess  over  sacroiliac  articulation.  Iodoform  emulsion  injected. 

November  1st,  Operation,  Ether,  Dr.  Halsted. — Exploration  of  right 
sacroiliac  joint.  Excision  of  the  walls  of  a  tuberculous  abscess  and  of  a  por- 
tion of  the  sacrum.  A  large  abscess  was  discovered  in  the  pelvis,  com- 
municating with  the  one  above.  The  walls  of  the  pelvic  abscess  were  cleaned 
as  well  as  possible,  but  some  portions  were  inaccessible  from  this  opening. 

February  3d. — Since  operation,  patient  has  been  kept  out-of-doors  in  bed, 
but  her  weight,  which  is  normally  135  pounds,  is  now  only  98.  She  has  been 
most  carefully  instructed  as  to  the  life  out-of-doors,  and  has  promised  to  fol- 
low directions  implicitly.   Discharged. 


148  OPEN-AIR  TREATMENT 

April  8,  190 It. — Patient  returns  for  examination.  She  is  in  perfect  health 
and  weighs  150  pounds.  Since  leaving  the  hospital,  two  years  ago,  she  has 
lived  out-of-doors  faithfully  in  all  weathers ;  has  slept  indoors,  but  with  win- 
dows wide  open.  The  sinus  leading  to  the  pelvis  is  closed.  There  is  no  sign 
of  disease  in  the  pelvis  or  at  the  site  of  the  incision  in  the  back.  She  com- 
plains of  nothing  except  that  on  standing  she  has  slight  pains  along  the 
course  of  the  sciatic  and  external  popliteal  nerves.  Extreme  flexion  of  thigh 
sometimes  produces  this  pain.  Patient  is  not  annoyed  by  it. 

Case  VII. — Miss  B e,  aged  16.    Admitted  to  The  Johns  Hopkins 

Hospital,  March  25,  1904.  About  three  months  ago  patient  noticed  that  her 
neck  on  both  sides  was  swollen,  and  believed  the  swelling  to  be  due  to 
"  cold."  The  "  puffiness  "  soon  subsided,  leaving  "  knots  "  in  its  place. 
These  have  grown  rapidly  ever  since.  There  has  been  no  pain  nor  tender- 
ness and,  patient  believes,  no  loss  in  weight;  she  confesses  to  some  loss  of 
strength.  The  voice  has  become  husky.  Patient  is  becoming  drowsy,  and 
has  tendency  to  sleep  continually.   No  cough. 

Examination. — On  both  sides  of  the  neck  are  large  masses  of  discrete 
glands,  varying  in  size  from  a  pea  to  a  Madeira-nut.  Together  they  would 
probably  equal  a  cocoanut  in  volume.  Left  axilla  contains  six  or  seven 
glands ;  the  right  seems  free.  The  left  epitrochlear  is  palpable.  No  enlarge- 
ment of  glands  of  groin  or  popliteal  space.  No  masses  to  be  felt  in  abdomen. 
Spleen  not  palpable.  Tonsils  markedly  enlarged.  Circumference  of  neck 
at  level  of  hyoid  bone,  34  cm.  On  the  back  of  the  right  hand  is  a  scar  from 
incision  for  the  removal  of  a  small  growth,  believed  at  the  time  to  be  a  gan- 
glion, but  which  proved  to  be  a  solid  mass.  There  is  now  an  elongated, 
semifluctuant  swelling  apparently  connected  with  the  tendon  sheaths.  A 
small  gland  removed  for  diagnosis  proved  to  be  tuberculous.  It  was  pro- 
posed to  patient  and  her  friends  that  the  out-of-door  treatment  be  tried 
and,  in  case  it  failed,  operation  be  undertaken.  The  patient  being  indis- 
posed to  undergo  the  rigorous  out-of-door  life,  Dr.  Follis,  the  house  sur- 
geon, excised,  with  cocaine,  the  tuberculous  glands  of  the  left  neck  and  left 
axilla. 

April  10th. — Patient  discharged,  having  promised  to  live  systematically 
out-of-doors.   Wound  healed  per  primam. 

Readmitted  May  12,  1904.  Since  discharge  patient  has  lived  out-of-doors, 
day  and  night,  without  interruption.  Though  she  has  had  only  one  month 
of  this  treatment,  the  glands  on  the  right  side  of  the  neck  have  almost 
entirely  disappeared.  Only  one  can  be  felt,  and  that  exceedingly  small. 
On  the  back  of  the  left  hand,  however,  at  the  site  of  the  old  scar  and  run- 
ning along  the  tendon  sheaths,  there  is  evidence  of  a  tuberculous  process. 

May  13th. — Excision  of  tuberculous  tissue  about  the  extensor  tendons 
over  the  left  wrist  and  dorsum  of  hand,  by  Dr.  Follis.  The  disease  was 
found  to  be  quite  extensive. 

June  6th. — Patient  discharged.  Condition  excellent.  No  enlargement  of 
glands  of  neck.  On  the  operated  side,  however,  is  a  keloidal,  disfiguring 
scar. 

Case  VIII.— M s,  aged  25.   Admitted  April  11,  1904.   Tuberculosis 

of  right  knee.  About  three  years  ago,  after  prolonged  standing,  experienced 


SUEGICAL  TUBERCULOSIS  149 

first  pain  in  the  right  knee.  He  was  treated  for  acute  rheumatism  for  six 
months,  the  knee-joint  being  aspirated  25  times.  The  fluid  withdrawn  was 
dark  and  turbid,  but  never  bloody.  On  one  occasion  an  injection  of  carbolic 
acid  solution  (1  to  16)  was  used.  Patient's  knee  gave  him  little  trouble 
apparently  until  September,  1903. 

Examination. — Joint  much  enlarged.  Patella  floating.  No  redness,  heat, 
nor  especial  tenderness.  Leg  can  be  flexed  to  about  a  right  angle.  April  13, 
tuberculin  administered.  Marked  local  and  general  reaction.  April  25, 
arthrotomy,  under  ether,  by  Dr.  Follis.  A  considerable  amount  of  purulent- 
looking  tuberculous  fluid  was  evacuated  and  the  joint  thoroughly  irrigated 
with  a  solution  of  mercury  bichloride  (1  to  10,000).  The  capsule  was  found 
thickened  and  oedematous,  but  there  was  no  evidence  of  bone  foci  nor  de- 
struction of  cartilage,  nor  caseous  tissue.  On  June  4,  Dr.  Follis  persuaded 
patient  to  go  to  Saranac  Lake  in  the  Adirondacks,  and  arranged  for  his 
admission  to  Dr.  Trudeau's  sanatorium.  Discharged  today. 

April  11,  1904,  patient  readmitted  to  hospital.  Since  his  discharge  he  has 
been  continuously  at  Saranac  Lake.  The  knee  has  been  fixed  in  a  leather 
splint.  Patient  has  gained  ten  pounds  since  leaving  hospital.  He  has  no 
cough  nor  night  sweats,  and  appetite  is  good. 

April  14th,  2  mg.  of  tuberculin  administered,  followed  by  severe  reaction. 

Examination  of  Knee. — The  joint  is  spindle-shaped,  there  being  consid- 
erable atrophy  of  the  thigh  muscles.  The  patella  is  movable,  and  there  is 
little  or  no  fluid  in  the  knee-joint.  There  are  no  points  of  especial  tender- 
ness on  pressure,  but  attempts  to  flex  the  joint  beyond  perhaps  15  degrees 
cause  great  pain.  The  findings  are  somewhat  disappointing,  but  patient  is 
not  discouraged,  and  agrees  henceforth  to  live  out-of-doors  at  night,  as  well 
as  in  the  day  time,  at  his  home  in  Montgomery,  Ala.  Discharged  March  18th. 

October,  1905,  patient  readmitted  to  the  hospital.  Since  March  he  has 
lived  out-of-doors  night  and  day  in  Montgomery,  Ala.,  and  has  noticed  from 
the  beginning  gradual  improvement  in  the  condition  of  the  knee-joint. 
He  looks  in  robust  health,  has  had  no  pain  in  knee  or  elsewhere.  Has  used 
crutches  and  a  leather  splint. 

Examination. — The  knee  seems  perfectly  cured.  Flexion  is  permitted 
without  any  pain  to  an  extent  almost  normal.  Except  for  the  scar  and  the 
barely  perceptible  fulness  in  its  neighborhood,  for  which  the  scar  is  prob- 
ably responsible,  the  joint  in  appearance  is  perfectly  normal. 

October  13th,  2  mg.  of  tuberculin  are  followed  by  sharp  reaction,  the  tem- 
perature rising  abruptly  to  102°. 

Case  IX. — Miss n,  aged  17.    Consulted  me  last  March.    Below  the 

parotid  in  the  common  situation  on  the  jugular  vein  was  a  mass  of  matted 
glands,  larger  than  a  big  lemon.  They  had  increased  in  size  rapidly  during 
the  few  weeks  prior  to  this  consultation.  Not  wishing  to  alarm  the  young 
lady  unnecessarily,  I  did  not  give  tuberculin  at  once  but  sent  her  to  the 
seashore  with  a  skilled  attendant  for  out-of-door  treatment.  In  about  a 
month  she  returned  for  inspection.  The  mass  had  increased  in  size  and 
become  fluctuant  in  the  most  prominent  part,  and  the  skin  over  it  was  in- 
flamed and  at  one  spot  slightly  thinned.  Tuberculin  administered  was  fol- 
lowed by  a  sharp  reaction.   About  to  sail  for-  Europe,  I  doubted  very  much 


150  OPEN-AIR  TREATMENT 

the  wisdom  of  postponing  operation,  and  debated  the  matter  in  my  mind 
for  several  days. 

Argument. — If  an  operation  were  performed,  it  would  not  make  the  out- 
of-door  treatment  unnecessary  or  even  shorten  it.  If  the  skin  should  break, 
the  resulting  scar  would  be  much  less  than  the  operative  one.  The  rupture 
of  the  abscess  would  not  be  attended  with  any  bad  results,  nor  would  it, 
that  we  know,  prolong  the  open-air  treatment  or  create  local  conditions  less 
likely  to  respond  to  this  treatment  than  if  the  skin  were  unruptured.  If 
ultimately  an  operation  should  be  required,  it  would  almost  surely  be  of  less 
magnitude  and  at  a  time  when  the  patient  was  more  robust.  Moreover,  it 
transpired  that  our  patient  had,  at  the  seashore  from  which  she  had  just 
returned  unimproved,  lived  only  five  or  six  hours  daily  in  the  open  air. 
So  we  decided  to  give  the  open  air  a  fairer  trial. 

She  went  to  the  coast  of  Maine  and  lived  out-of-doors  day  and  night  for 
about  four  months.  A  few  days  ago,  on  her  return  to  town,  I  examined  her 
and  to  my  joy  found  that  only  one  of  the  enlarged  and  inflamed  glands  was 
palpable  and  this  no  larger  than  a  French  bean.  The  redness  of  the  skin 
had  entirely  disappeared  and  I  do  not  believe  that  any  one  from  the  appear- 
ances could  have  designated  the  side  which  had  been  affected.  To  surgeons 
whose  daily  bread  not  long  ago  was  tuberculous  glands  of  the  neck  (Cohn- 
heim)  such  a  resolution  foretells  a  revolution  in  treatment. 

Cases  X  and  XI. — Two  cases  of  tuberculosis  of  the  urinary  bladder, 
adult  males.  Operated  upon  by  the  author  at  The  Johns  Hopkins  Hospital 
in  1892  and  1893.  In  one,  the  entire  mucous  membrane  of  the  bladder  was 
thickly  studded  with  tubercles;  in  the  other,  the  involved  area  was  small 
and  the  disease  incipient.  Both  cases  have  been  quite  constantly  under 
observation  since  their  discharge,  and  both  are  in  good  health.  The  one 
with  the  severe  and  extensive  lesions  was  able  to  lead  the  out-of-door  life 
quite  constantly.  He  is  well.  The  other,  with  the  comparatively  trivial 
lesions,  has  trifled  with  the  treatment  and  is  not  perfectly  well,  although 
very  much  better  than  when  he  was  operated  upon  about  15  years  ago.  The 
histories  of  these  cases  are  not  at  hand,  so  I  am  unable  to  report  them  in 
full  and  to  give  exact  dates. 

The  Moke  Complete  Histories  of  the  First  Four  Cases 

Case  I. — In  February,  1890,  the  writer  was  summoned  to  see  Mr. n, 

who  at  the  time  was  so  ill  that  his  life  was  despaired  of  by  his  relatives. 
The  patient,  aged  28,  received  a  severe  fall  when  at  the  age  of  3,  to  which 
was  attributed  the  illness  and  spinal  curvature,  which  thereafter  speedily 
developed.  At  the  age  of  14,  incident  to  a  second  fall  on  his  back,  an  ab- 
scess developed  rapidly  and  discharged  in  the  right  groin.  It  soon  closed, 
but  only  to  reopen  and  close  again  at  intervals  ever  since.  In  the  winter  of 
1888  and  1889,  abscesses  appeared  and  opened  spontaneously  in  the  left 
groin  and  above  the  crest  of  the  left  ilium.  Thereupon  the  patient's  health 
declined  rapidly  until  March,  1890,  when  my  first  visit  was  paid  him. 

At  this  time  he  had  sharp  lower-dorsal  kyphosis,  an  enormous  liver  and 
three  sinuses,  one  on  each  side,  below  Poupart's  ligament,  and  one  above 
the  crest  of  the  left  ilium.  For  several  weeks  the  patient,  considerably  ema- 


SURGICAL  TUBERCULOSIS  151 

ciated,  had  experienced  chilly  sensations,  and  occasionally  a  real  chill,  with 
high  fever.  He  was  evidently  suffering  from  retention  under  tension  of  the 
products  of  inflammation,  which,  I  believed,  from  rather  indefinite  symp- 
toms, would  point  over  the  right  ilium.  As  he  was  very  feeble  and  exceed- 
ingly nervous,  as  the  indications  for  immediate  operation  were  not  per- 
fectly clear,  and  as  his  life  at  home  involved  considerable  excitement,  I 
urged  him  to  go  at  once  to  Saranac  Lake  in  the  Adirondacks,  intending  to 
visit  him  later  and  to  liberate  the  pus  if  the  symptoms  should  persist.  It 
required  very  little  argument  to  convince  this  highly  intellectual  and  ac- 
complished man  that  it  was  well  worth  while  to  make  the  experiment.  He 
was  transported  on  a  bed  in  a  private  car  from  Baltimore  to  Saranac  Lake ; 
this  patient  was  a  pioneer,  and  possibly  the  very  first  case  of  bone  tuber- 
culosis deliberately  treated  by  the  open-air  method.  In  the  Adirondacks, 
attended  by  an  excellent  masseur,  he  lived  in  a  tent,  and  almost  immedi- 
ately after  arrival,  an  improvement  in  his  general  condition  began,  although 
there  were  periods  when  the  daily  fever  would  be  considerable. 

In  October,  1890,  I  visited  him  at  Paul  Smith's,  where  he  had  located  his 
tent,  and  performed  a  slight  operation  to  liberate  the  pus  on  the  right  side 
above  the  crest  of  the  ilium.  Two  years,  with  occasional  visits  to  his  home 
in  Baltimore,  were  spent  in  the  Adirondacks.  In  this  time  the  patient  was 
literally  transformed  in  appearance.  Weighing  less  than  100  pounds  on 
arrival,  he  gained  nearly  40  pounds  from  April,  1890,  to  November,  1891, 
and  on  his  return  to  Baltimore  he  affirmed  that  he  had  never  felt  better  in 
his  life.  His  good  health  continuing,  he  became  engaged,  and  in  about  two 
years  he  married.  After  his  marriage  he  spent  a  part  of  two  or  three  winters 
in  the  Adirondacks,  with  great  benefit  to  his  health.  Occasionally  I  found 
it  necessary  to  dilate  one  or  more  of  his  sinuses  in  order  to  liberate  their 
pent-up  discharges.  On  July  29,  1902,  the  patient  died,  the  immediate 
cause  of  death  being  an  exacerbation  of  the  nephritis,  which  had  existed  for 
12  years  at  least.  The  liver,  which  was  very  large  and  extended  below  the 
umbilicus  at  my  first  examination,  steadily  increased  in  size  during  the  sub- 
sequent 12  or  13  years.  In  the  last  four  or  five  years  of  his  life  he  suffered 
on  two  or  three  occasions  from  attacks  of  acute  nephritis,  precipitated  ap- 
parently by  the  toxaemia  resulting  from  obstruction  in  one  or  other  of  the 
sinuses. 

This  was  a  life  clearly  rescued  and  prolonged  by  the  Adirondacks  and 
Dr.  Trudeau.  This  patient  had  such  confidence  in  the  ability  of  these  moun- 
tains to  restore  him  at  any  time  that  he  lived  not  only  a  most  unhygienic 
but  actually  reckless  life  at  home,  repairing  to  Saranac  Lake  only  when 
his  condition  sufficiently  alarmed  him.  Three  superb  children  survive  him, 
to  bless  the  Adirondacks  and  the  physician  there  who  made  their  introduc- 
tion to  this  world  possible.  Consideration  for  his  wife  and  children,  he 
often  told  me,  would  not  permit  him  to  make  his  home  in  the  Adirondacks. 
A  few  days  after  his  death  his  sister  wrote  me  that  "  of  the  large  circle  of 
acquaintances  made  in  the  Adirondacks,  only  one  of  those  who  were  suffer- 
ing with  tuberculosis  is  alive  today.  My  brother,  although  apparently  the 
illest  of  all,  survived  them.  In  other  words,  I  believe  the  treatment  promises 
more  for  bone  trouble  than  for  pulmonary  tuberculosis."  I  quote  this,  of 
course,  merely  to  give  the  impression  of  an  intelligent  lay  observer.   That 


152  OPEX-AIE  TEEATMEXT 

this  patient  could  have  been  rescued  elsewhere  than  in  the  Adirond; 
quite  likely,  but  having  tested  the  mountains  of  Virginia,  the  sea  coast  of 
New  Jersey  and  Maryland,  he  had  faith  only  in  the  Adirondacks.  One 
Christmas,  about  two  years  after  his  introduction  to  the  Adirondacks,  he 
returned  to  Baltimore,  and,  though  wearing  a  heavy  overcoat  on  a  mild 
winter  day,  complained  bitterly  of  the  cold.  u  I  am  wearing  today  an  over- 
coat for  the  first  time  this  winter,"  said  he,  "  although  the  thermometer  has 
been  as  low  as  20°  below  zero  in  the  Adirondacks.  Up  there  one  is  ins 

i  the  severest  cold,  but  here  one  shivers  on  a  mild  day/'  His  masseur, 
walking  with  him,  had  already  made  the  same  remark  to  me. 

SB   II. — Miss  n,  aged  15.  consulted  me  for  the  first  time  in 

.  For  about  18  months  she  had  suffered  with  pains  in  her 
right  hip  and  knee. 

Tuberculosis  on  both  maternal  and  paternal  sides  was  conspicuous  in 
the  family  history,  but  the  patient  had  been  perfectly  healthy  until  the 
onset  of  the  present  trouble. 

— Eight  thigh  much  flexed  and  slightly  adducted.  All  mo- 
tions of  hip-joint  greatly  restricted.  There  was  so  much  fulness  about  the 
right  hip  that  an  abscess  was  suspected,  and  a  needle  aimed  at  the  joint 
was  readily  introduced  into  a  space  believed  to  be  or  to  communicate  with 
the  joint  cavity.  The  point  of  the  needle  could  be  moved  freely,  as  if  in  an 
abscess,  and  from  one  and  a  half  to  two  ounces  of  a  glycerine  emulsion  of 
iodoform  was  at  the  nest  consultation  injected  without  meeting  resistance. 
Patient  was  kept  in  bed  in  a  large,  freely- ventilated  room,  with  extension, 
from  February  until  June,  1893.  During  these  four  months,  five  or  six 
iodoform  injections  were  made.  After  the  first  two  or  three  injections  it 
was  difficult  to  find  the  abscess  cavity.  A  light  Brans'  splint  was  applied, 
and,  faithfully  following  my  urgent  advice,  the  patient  lived  out-of-<loors 
thenceforth ;  extension  was  kept  up  at  night.  For  the  ensuing  five  years  she 
spent  from  six  to  eight  hours  daily  in  the  open  air.  The  summers  of  these 
years  were  lived  in  the  low  mountains  near  Wilkesbarre,  Pa.  Patient's  gen- 
eral health  was  fairly  good  most  of  the  time,  but  she  was  far  from  robust, 
and  her  appetite  was  unsatisfactory.  The  eight  or  ten  pounds  which  were 
gained  each  summer  in  the  mountains  of  Pennsylvania  were  lost  in  the 
winter. 

In  June,  1898,  patient  was  admitted  for  a  few  days  to  my  service  in 
The  Johns  Hopkins  Hospital,  for  measurements  and*  a  skiagraph.  The 
summer  of  1899  was  spent  at  Jamestown,  B.  I.  Xo  gain  in  weight  was  made 
at  the  seashore  and  patient  returned  to  her  home  near  Baltimore  unim- 
proved, and  out  of  conceit  with  the  seaside.  In  January,  1900,  patient  was 
again  admitted  to  The  Johns  Hopkins  Hospital  for  careful  examination 
subsequent  to  a  period  in  which  greater  liberties  in  walking  had  been  per- 
mitted. It  was  deemed  wise  to  make  an  exploratory  incision  before  permit- 
ting patient  to  dispense  entirely  with  her  cratches.  The  result  of  this 
operative  examination  was  most  satisfactory.  The  head  of  the  femur  had 
been  entirely  absorbed,  but  the  neck  was  intact  and  perfectly  norm 
free  end  occupying  the  remains  of  the  acetabulum.  A  narrow,  deep  groove 
was  cut  anteriorly  into  the  neck  for  its  entire  length,  but  not  the  slightest 
evidence  of  disease  was  discovered.   The  slight  shortening  which  had  been 


SUEGICAL  TUBEECULOSIS  153 

observed  on  Bryant's  line  was  evidently  due  solely  to  the  loss  of  the  head  of 
the  femur.  The  capsule  of  the  hip-joint  was  intact  and  motion  between  the 
articulating  inner  end  of  the  neck  and  the  acetabulum  was  remarkable  in 
its  freedom.  Mature  had  accomplished  what  a  surgeon  by  operation  could 
not  possibly  have  done.  A  surgical  operation,  even  the  most  conservative, 
is  necessarily  destructive,  even  if  nothing  more  is  attempted  than  the  re- 
moval of  inflammatory  products  or  of  tissues  already  destroyed.  Patient 
was  discharged  February  7,  having  been  detained  in  the  hospital,  after  the 
operation,  only  1\  weeks. 

January  8,  1900,  the  day  before  the  exploration  of  the  hip,  the  red  blood- 
corpuscles  were  3,250,000;  the  white,  6000;  the  haemoglobin,  52  per  cent. 

January  28th,  10  days  later,  and  9  days  postoperative,  the  haemoglobin 
was  65  per  cent.  February  3,  haemoglobin,  65  per  cent. 

Comparing  the  measurements  made  by  me  in  June,  1898,  with  those 
made  independently  by  my  house  surgeon,  Dr.  Cushing,  18  months  later, 
it  is  interesting  to  note  that  the  relative  differences  are  precisely  the  same. 
This  would  indicate  that  the  disease  had  made  no  progress  whatever  and 
that  the  measurements  were  exceedingly  accurate. 

June  7,  1898,  measurements  by  "W.  S.  Halsted.  Apparent  difference  in 
length  of  the  legs,  none.  From  anterior  superior  spine  to  trochanter,  on 
projected  vertical  line : 

Left  Right 

(a)  Vertical    line    (Bryant's) 22  cm.  1.9  cm. 

(b)  Ant.  sup.  spine  to  int.  malleolus 83.9  cm.  S0.9  cm. 

(c)  Top  of  trochanter  to  ext.  malleolus 84.1  cm.  81      cm. 

(d)  Length    of    femur 44.6  cm.  44.1  cm. 

January  17,  1900,  two  days  before  the  exploration  of  the  hip.  Notes  by 
H.  W.  Cushing.   Apparent  difference  in  length,  none. 

Left  Right 

Ant.  sup.  spine  to  int.  malleolus 83     cm.        SO  cm. 

Trochanter  to  ant.  sup.  spine  (Bryant's  line) 4.5  cm.  4  cm. 

No  muscle  spasm.  Internal  and  external  rotation  only  slightly  limited 
if  at  all.  Extension  to  straight  line  and  flexion  permitted  to  45°  or  more, 
notwithstanding  the  prolonged  fixation  of  the  joint. 

The  measurements  indicate  abduction.  The  apparent  upriding  of  the 
right  trochanter  is  in  part  due  to  the  abduction.  That  there  is  so  little  meas- 
ured difference  (0.5  cm.)  in  the  length  of  the  femur,  notwithstanding  the 
growth  of  the  patient,  might  suggest  a  thickened  right  trochanter.  But  the 
loss  of  the  head  of  the  femur,  together  with  the  abduction,  should  sufficiently 
account  for  the  1.9  cm.  shortening  in  Bryant's  line.  How  shall  we  interpret 
the  fact  that  the  difference  (3  cm.)  in  the  length  of  the  lower  extremities  is 
almost  entirely  in  the  leg,  unless  we  assume  that  the  disease  stimulated, 
as  it  sometimes  does,  the  growth  of  the  bone  on  its  confines  ?  The  circum- 
ference of  the  calf  was  the  same  on  the  two  sides,  whereas  there  was  a  differ- 
ence of  4  cm.  in  the  circumference  of  the  thighs,  15  cm.  above  the  patella. 
The  shortened  leg  was  larger  and  the  atrophied  thigh  was  longer  than 
expected. 


154  OPEN-AIR  TREATMENT 

Prom  the  hospital  the  patient  went  to  the  Adirondacks  for  five  weeks, 
and  while  there  gained  11  pounds.  She  learned  for  the  first  time  the  true 
meaning  of  living  out-of-doors,  and  was  so  conscious  of  the  great  and  prompt 
benefit  received  that  she  regretted  the  long  doubtful  years  lived  on  the  piazza 
at  home.  It  is  but  just  to  myself  to  state  that  at  the  first  consultation,  and 
often  subsequently,  I  had  suggested  and  even  urged  the  Adirondacks,  but 
was  unable,  when  questioned  as  to  the  relative  merit  of  localities,  to  affirm 
that  the  Adirondacks  alone  promised  relief,  or  more  certainly  promised  it 
than  the  mountains  elsewhere.  I  could  only  answer  that  the  Adirondacks 
had  been  tested  more  thoroughly  and  more  scientifically  than  any  other 
region  in  this  country,  and,  what  was  most  important,  the  patient  residing 
there  would  be  under  Dr.  Trudeau's  supervision,  and  would  learn  to  lead 
the  proper  life. 

On  her  return  from  the  Adirondacks  the  crutches  were  abandoned,  and 
our  patient  promptly  found  great  enjoyment  in  life,  riding,  driving,  walk- 
ing, dancing,  and  indulging  freely  in  the  pleasures  of  society.  Finding  the 
out-of-door  life  irksome  and  incompatible  with  the  new  life  into  which, 
after  the  long  confinement,  she  was  entering  so  naturally  and  with  so  much 
relish,  the  hours  on  the  piazza  became  fewer  and  fewer,  until  finally  in 
the  winter  (1900-1901)  there  were  none.  Day  after  day  and  night  after 
night,  during  this  winter,  our  patient's  strength  would  be  tested  to  the 
extreme  limit  of  endurance.  The  summer  of  1901  was,  in  greater  part, 
passed  in  Maryland.  About  the  first  of  December  (1901)  I  was  consulted 
concerning  a  little  swelling  and  a  little  stiffness  about  the  right  wrist-joint, 
which  had  been  observed  for  about  two  months.  Tuberculosis  of  the  tendon 
sheaths  being  diagnosticated,  our  patient,  who  had  lost  in  weight  and 
strength,  was  at  once  admitted  to  The  Johns  Hopkins  Hospital  and  promptly 
operated  upon. 

There  was  much  oedema  of  the  tendon  sheaths.  Fresh,  translucent  tuber- 
cles thickly  studded  the  connective  tissues  and  muscles  of  the  forearm, 
particularly  the  tendon  sheaths,  from  the  palm  of  the  hand  to  the  upper 
third  of  the  forearm.  A  very  careful  dissection  of  the  tissues  involved  and 
excision  of  the  disease  was  made.  December  18,  about  two  weeks  after 
operation,  the  patient  was  discharged,  and  about  January  1,  1902,  eagerly 
started  for  the  Adirondacks.  Arrived  at  Saranac,  she  began  to  improve  in 
health  immediately,  gaining  16  pounds  in  the  first  month.  The  remainder 
of  this  winter  and  the  following  spring  were  passed  at  Saranac,  the  best  of 
health  being  enjoyed.  The  summer  was  spent  in  the  Austrian  Tyrol. 

April  8, 1905. — Patient  has  enjoyed  perfect  health,  almost  without  inter- 
ruption, since  her  return  to  the  Adirondacks  in  January,  1902.  For  the 
past  two  and  a  half  years  she  has  lived  at  her  country  home  near  Baltimore. 
Today  she  is  the  picture  of  health.  The  affected  forearm,  wrist  and  hand 
present  a  normal  appearance,  except  for  the  scar,  and  perform  their  func- 
tions quite  normally.  Patient  would  be  rarely  reminded  of  the  fact  that  her 
right  hip-joint  was  once  the  site  of  serious  tuberculous  disease  were  it  not 
for  a  very  slight  limp,  suggesting  the  use  of  a  cane  when  she  is  tired. 

This  case  teaches  us  that  a  brief  period  of  time  is  of  great  importance  in 
the  treatment  of  tuberculous  joints  in  fast-growing  children,  because  of  the 


SURGICAL  TUBERCULOSIS  155 

shortening  which  results,  particularly  from  disuse.  In  this  case,  the  short- 
ening from  disease,  represented  by  the  difference  in  the  height  of  the  tro- 
chanter, is  only  .5  cm.,  whereas  the  difference  in  length  of  limb  from 
trochanter  to  malleolus  is  3.25  cm. 

Case  III. — Mrs. d.  First  consultation  March  16,  1894.  Married  two 

years  before,  at  the  age  of  26. 

In  November,  1894,  lost  a  sister,  aged  36,  of  pulmonary  tuberculosis. 

About  the  first  of  March,  1894,  patient  "  felt  a  slipping  sensation  "  in  the 
right  knee.  History  of  traumatism  could  not  be  elicited.  She  at  once  con- 
sulted the  late  Dr.  Dabney,  professor  of  medicine  in  the  University  of  Vir- 
ginia, and  by  Dr.  Dabney  was  referred  to  me. 

Examination,  March  16, 189.!+. — A  delicate-looking,  very  slender,  nervous, 
and  emotional  young  woman;  has  always  enjoyed  good  health  until  about 
two  weeks  ago,  when  she  began  to  worry  about  her  right  knee.  There  is 
slight  limitation  of  motion ;  a  little  disability ;  some  fluid  in  the  joint ;  and 
apparent  thickening  of  the  capsule ;  two  or  three  typical  tender  points.  The 
lungs  and  other  organs  are  reported  normal. 

Diagnosis. — Tuberculosis  of  the  right  knee. 

I  advised  Dr.  Dabney  to  fix  the  knee  in  plaster,  and  to  make  iodoform  in- 
jections into  the  joint,  and  urged  the  patient  to  lead  at  her  home  in  the 
South  the  Adirondack  life,  which  I  described  to  her.  Four  injections  were 
made  by  Dr.  Dabney  from  April  7th  to  May  18th. 

June  15th. — Second  consultation.  Finding  the  knee  unimproved,  I  ad- 
vised change  of  residence  to  the  mountains,  preferably  the  Adirondacks. 
Mountains  near  home,  altitude  1900  feet,  were  visited,  because  residence 
in  the  Adirondacks  was  not  feasible  at  this  time.  Dr.  Dabney  made  a  fifth 
iodoform  injection,  June  20th,  and  a  sixth,  July  12th.  In  August  he  died. 
The  seventh,  eighth,  ninth  and  tenth  injections  were  made  by  me  in  Balti- 
more in  October  and  November,  1894,  and  January  and  March,  1895. 
About  October,  1895,  I  advised  resection  of  the  knee,  as  the  disease  was 
advancing,  as  the  patient's  health  was  becoming  decidedly  impaired,  and 
as  a  winter  in  the  Adirondacks  was  deemed  impossible  by  the  patient  and 
her  husband.  Patient  returned  to  Baltimore,  November  4,  1895,  for  opera- 
tion. For  two  or  three  weeks  patient  had  coughed  occasionally.  November 
5th  I  carefully  examined  the  lungs  and  feared  that  both  apices  were  becom- 
ing involved.  November  6th  a  second  examination  confirmed  my  fears.  The 
operation  was  consequently  postponed,  and  the  patient  urged  to  go  at  once 
to  the  Adirondacks.  November  8th  she  expectorated  a  little  blood  just  before 
starting  for  the  Adirondacks.  At  this  time  her  weight  was  86  pounds.  Her 
normal  weight  was  about  104,  and  her  greatest  weight  112  pounds. 

Soon  after  her  arrival  at  Saranac  Lake,  Dr.  Trudeau  made  several  careful 
examinations  and  feared  that  the  disease,  although  incipient,  was  rapidly 
advancing,  and  gave  an  unfavorable  prognosis.  For  several  months  there 
was  no  improvement,  but  the  patient  held  her  own  and  finally  began  to  gain 
in  weight  and  in  August,  1896,  weighed  95  pounds.  She  then  felt  compelled 
to  leave  the  Adirondacks,  contrary  to  Dr.  Trudeau's  advice  and  my  earnest 
solicitations.  I  suggested  the  higher  mountains  of  western  North  Carolina 
as  an  alternative,  but  patient  was  so  much  encouraged  that  she  decided  to 


156  OPEN-AIR  TREATMENT 

go  again  to  the  mountains  nearer  her  home  in  Virginia.  Slowly  but  cer- 
tainly losing  ground,  she  eventually,  in  October,  1897,  went  to  the  western 
North  Carolina  mountains.  Having  learned  in  the  Adirondacks  how  she 
should  live  and  what  the  out-of-door  life  meant,  she  lived  out-of-doors  in 
all  weathers  faithfully,  and  became  very  fond  of  the  life. 

In  September,  1898,  I  found  great  improvement,  both  in  her  general 
health  and  in  the  condition  of  the  knee.  Early  in  1899  the  patient's  casts 
were  discontinued.  In  May,  1899,  patient  located  permanently  in  Hender- 
sonville,  N.  C.  The  altitude  of  her  private  residence  there  is  about  2250  feet. 
Her  weight  at  this  time  was  97  pounds.  Full  of  hope  of  ultimate  recovery, 
she  visited,  without  my  consent,  her  relatives  in  Virginia  in  January  and 
February,  1900,  and  as  she  wrote  me,  "  lost  considerable  ground."  On  re- 
turning to  Hendersonville,  it  was  two  or  three  months  before  she  regained 
what  she  had  lost. 

In  November,  1900,  I  had  the  pleasure  of  seeing  my  patient  and  finding 
her  general  condition  somewhat  improved  and  her  knee  disproportionately  so. 

January,  1901,  patient  writes  that  the  knee  is  surely  becoming  less  stiff. 

A  little  later  patient  ventured,  against  my  most  urgent  warning,  another 
visit  to  her  home  in  Virginia,  to  see  her  aged  mother  whose  health  was  not 
good.  She  had  an  attack  of  "  pleurisy  "  while  at  home  and  only  with  diffi- 
culty could  return  to  Hendersonville. 

Some  months  later,  January,  1903,  she  writes  from  Hendersonville  that 
she  weighs  only  85  pounds,  that  her  "health  is  extremely  frail,"  but  that 
the  knee  is  "  vastly  improved."  She  "  can  bear  some  weight  on  it "  and 
goes  "  about  the  house  with  only  one  crutch."  "  Creaking  and  grating  in  the 
joint  if  exercised  still  noticeable  to  sense  of  hearing  and  touch.  Motion  very 
nearly  normal." 

September  28, 1908. — Met  my  patient,  by  appointment,  on  a  railway  train 
and  examined  the  knee-joint.  In  appearance  the  joint,  except  for  a  very 
slight  fulness  on  either  side  of  the  ligamentum  patellae,  showed  nothing 
abnormal ;  the  patient  flexed  and  extended  her  knee  rapidly  and  without  the 
least  apprehension.  Flexion  of  the  left  or  sound  knee  could  be  carried  only 
5  or  6  degrees  further  than  of  the  right.  There  were  no  tender  points.  That 
such  a  restoration  of  function  could  take  place  in  this  knee,  at  one  time  so 
seriously  involved,  I  would  have  believed  hardly  possible.  It  was  the  more 
remarkable  because  the  patient's  general  health  was  very  poor  indeed.  She 
was  highly  neurotic,  suffering  from  tongue  and  stomach  neurosis,  and 
weighed  only  76  pounds.  I  had  no  opportunity  to  examine  the  lungs,  but 
was  assured  that  she  had  neither  cough  nor  expectoration,  and  rarely  if  ever 
had  a  night  sweat.  Her  respiration  was  not  rapid  as  she  sat  quietly  in  the 
car,  nor  was  there  anything  in  the  voice  or  facies  to  indicate  implication  of 
the  lungs. 

There  can  be  little  doubt  that  this  patient's  life  was  saved  by  the  Adiron- 
dacks and  the  North  Carolina  mountains.  She  believes  that  she  gained  much 
more  rapidly  in  the  former  than  in  the  latter  region.  The  almost  disastrous 
results  of  the  two  trips  to  her  home  in  Virginia  were  probably  not  due  so 
much  to  the  journey,  which  was  not  a  long  one,  as  to  the  change  of  residence, 


SUKGICAL  TUBERCULOSIS  157 

for  she  had  repeatedly  taken  hard,  all  day  drives  in  the  mountains  without 
demonstrable  evil  effects. 

How  remarkable,  too,  and  significant,  is  the  observation  that,  notwith- 
standing the  gradual  and  great  loss  of  strength  and  weight,  the  tuberculous 
process  in  both  the  knee  and  the  lungs  was  not  only  arrested  but  has  left  no 
sign. 

Under  Dr.  Thayer's  care  this  patient  has  gained  more  than  20  pounds 
within  a  few  months ;  he  is  unable  to  find  a  trace  of  the  pulmonary  disease 
which  at  one  time  was  so  active  as  seriously  to  menace  her  life. 

Case  IV. — Surg.  No.  13010.    Miss  1,  aged  38.    First  examination 

February  7,  1902. 

Family  History. — Father  and  mother  living.  One  uncle  and  one  aunt  on 
mother's  side  died  of  pulmonary  tuberculosis.  A  sister  had  a  discharging 
sinus  from  one  hip,  but  was  cured  while  still  a  child.  Digestion  has  never 
been  very  strong,  and,  until  the  age  of  8,  patient  could  not  eat  breakfast 
without  vomiting  immediately.  At  12,  her  stomach  performed  its  functions 
fairly  well,  but  patient  has  always  found  it  advisable  to  be  abstemious.  Has 
never  had  a  chronic  cough  nor  haemoptysis,  nor  observed  any  unusual  short- 
ness of  breath.  A  year  ago  could  mount  ordinary  hills  on  a  bicycle  without 
fatigue.  Menses  have  always  been  regular.  Has  had  hay-fever  for  18  suc- 
cessive summers.  Several  of  the  finger-joints  and  one  ankle  are  enlarged 
from  "  chronic  rheumatism." 

Present  Illness. — Five  months  ago,  in  September,  1901,  making  a  false 
step,  patient  fell  backward,  down  three  steps,  striking  the  left  hip.  A  slight 
subcutaneous  extravasation  of  blood  appeared  over  the  left  trochanter,  and 
for  about  a  week  this  bruised  spot  was  tender.  There  was  no  limp  nor  pain 
on  walking,  and  the  incident  was  for  the  time  forgotten ;  but  about  January, 
1902,  the  left  hip  seemed  a  little  stiff  and  occasionally  felt  slightly  sore. 
These  symptoms  the  patient  tried  to  dissipate  by  walking.  After  about  a 
week's  exercise  of  this  kind,  a  tenderness  over  the  trochanter  manifested 
itself.  Improvement  followed  two  days'  rest  in  bed  but,  when  walking  was 
resumed,  the  discomfort  returned.  The  pain,  described  as  being  dull,  to  use 
the  patient's  words,  would  "  run  from  hip  to  knee,"  and  was  usually  worse 
at  night ;  "  it  felt  as  though  a  cord  were  stretched  too  tightly  from  the  hip 
over  the  knee."  A  few  weeks  before  admission,  a  decided  limp  manifested 
itself.  Patient  has  never  been  awakened  by  sharp  pains  at  night,  has  never 
had  night-sweats,  but  for  the  past  month  has  been  conscious  repeatedly  of 
chilly  and  feverish  sensations.  For  a  year  past  her  health  has  been  a  little 
below  what  she  considered  normal,  her  appetite  has  been  impaired,  she 
becomes  readily  fatigued,  and  has  lost  a  few  pounds  in  weight. 

February  12, 1902.  Physical  Examination. — Patient  is  a  slender,  delicate- 
looking  woman,  but  is  tall,  erect  and  well  formed.  Thorax  and  abdomen 
negative.  The  inguinal  glands  are  very  slightly  enlarged  on  both  sides. 

The  Hips. — Inspection  reveals  a  very  slight  apparent  shortening  of  the 
left  leg,  possibly  0.5  cm.,  and  little  else.  The  back  is  flat,  and  there  seems  to 
be  no  abnormal  flexion  of  either  hip. 


158  OPEN-AIR  TREATMENT 

Measurements  by  the  House  Surgeon 


Ant.  sup.  spine  to 
ext.  mall. 

Trochanter  to  mall. 

Ant.  sup.  spine  to 
trochanter 

Left  side,     85  cm. 

81.5  cm. 

3.7  cm. 

Right  side,  85  cm. 

81.5  cm. 

32  cm. 

The  0.5  cm.  difference  in  the  length  of  Brj-ant's  line,  if  correct,  I  believed 
to  be  due,  in  part  at  least,  to  the  abduction  of  the  right  and  adduction  of 
the  left  leg. 

All  the  motions  of  the  affected  left  side  seem  to  be  normal  if  they  are  made 
gently  and  with  suitable  traction.  Even  sudden  motions  are  not  definitely 
resisted,  except  abduction  and  extreme  adduction  and  internal  rotation. 
Flexion  and  extension  are  perfect.  Hyperextension  seems  about  equal  on  the 
two  sides. 

Except  for  the  apparent  shortening  (adduction),  the  slight  rigidity  of  the 
adductor  muscles,  and  the  tenderness  over  the  trochanter,  there  are  no 
definite  signs  of  irritation  in  or  about  the  left  hip-joint.  There  seems  to 
be  a  little  thickening  of  the  left  trochanter. 

Measurements  made  by  the  writer  differed  in  no  essential  particular  from 
those  given  above.  To  determine  accurately  the  distance  from  the  top  of  the 
great  trochanter  to  the  malleolus,  a  tape  measure  seems  to  the  writer  to  be 
unreliable,  because  one  cannot  make  proper  allowance  for  the  distance  the 
muscles  permit  one's  finger  on  each  side  to  press  in  over  the  trochanter 
toward  the  digital  fossa.  With  a  wooden  measure,  which  we  have  constructed 
somewhat  on  the  plan  of  a  shoemaker's  foot  rule,  this  source  of  error  is 
excluded. 

April  11,  1902. — Examination  by  writer,  (a)  Apparent  shortening,  1.3 
cm. ;  gluteal  fold,  1  cm.  lower,  (b)  From  spine  to  top  of  trochanter  on  pro- 
jected vertical  line  (Bryant's),  no  shortening,  (c)  From  anterior  sup.  spine 
to  ext.  malleolus,  no  shortening. 

Eotation  out  6°  to  7°  less  on  left  than  on  right  side.  Eotation  is  about 
4°  less  on  left  than  on  right  side.  Adduction  very  slightly  restricted,  hardly 
demonstrable ;  rigidity  of  adductor  muscles.  Flexion  and  extension  normal. 
Possibly  slight  impairment  of  hyperextension.  Exceedingly  indefinite  reac- 
tion to  2  mg.  and  4  mg.  of  tuberculin.  After  9  mg.  of  tuberculin,  the  tem- 
perature rose  to  101°  F.,  and  patient  complained  slightly  of  headache  and 
general  malaise.  The  tuberculin  at  this  particular  period  happened  to  be 
weaker  than  usual,  and  9  mg.  was  a  not  uncommon  dose.  Patient  was  dis- 
charged today,  having  been  under  observation  for  63  days.  Treatment,  ex- 
tension by  weights  and  pulley  at  night,  and  brace  during  the  day. 

The  days  were  passed  on  the  bridge.  Patient  intended  to  continue  in  all 
its  details  the  treatment  instituted.  This  she  did  most  conscientiously  and 
intelligently  under  the  care  and  heartiest  cooperation  of  Dr.  Joseph  S.  Miller, 
but  as  she  has  since  then  repeatedly  assured  me,  she  had  no  conception  of  the 
true  out-of-door  life  as  it  is  lived  in  the  Adirondacks  under  Dr.  Trudeau's 
supervision. 

October  80,  1902. — Readmitted  to  hospital  for  examination.  Since  first 
visit  has  had  very  little  pain  in  hip  in  the  day  time,  but  at  night  has  been 
occasionally  awakened  by  it,  particularly  by  sudden  jerkings. 


SURGICAL  TUBERCULOSIS  159 

Examination,  November  6,  1902. — The  motions  at  the  hip- joint  are  de- 
cidedly less  free  than  at  first  examination,  eight  months  ago.  Flexion,  which 
was  then  about  normal,  is  stopped  at  85°.  Rotation,  in  both  flexed  and  ex- 
tended positions,  is  much  restricted,  particularly  rotation  outward.  There  is 
pronounced  spasm  of  the  adductors  now,  whereas  at  first  rigidity  was  barely 
demonstrable.  The  trochanter  is  more  sensitive  to  pressure,  particularly  be- 
hind just  below  the  posterior  superior  angle  and  along  the  posterior  surface. 
The  circumference  of  both  thigh  and  calf  is  6  cm.  less  on  left  side.  Four 
milligrams  of  tuberculin  produced  marked  general  reaction  and  temperature 
of  102°  F.  The  change  for  the  worse  in  the  local  and  also  general  condition 
is  so  definite  that  our  patient  decided,  without  hesitation,  to  go  at  once  to 
the  Adirondacks. 

March  20,  1903. — Readmitted  to  the  hospital  for  examination  after  a 
winter  in  the  Adirondacks.  The  change  in  patient's  general  appearance  is 
very  striking,  although  she  has  gained  in  weight  only  five  pounds.  From 
the  appearance  of  her  face  and  neck  and  body  I  was  quite  sure  the  gain  in 
weight  had  been  greater.  Patient's  voice  is  stronger  and  her  flesh  much 
firmer.  There  has  been  of  late  no  pain  whatever  in  the  hip,  and  rarely  any 
discomfort. 

Measurements. — Apparent  shortening  .5  cm.  Flexion  permitted  easily  to 
right  angle  is  checked  only  by  stiffened  knee.  Inward  rotation  about  equal 
on  the  two  sides.  Outward  rotation  less  by  3°  to  5°  on  affected  side.  Abduc- 
tion limited  about  2°.  Adduction  same  on  both  sides.  There  is  no  fixed 
flexion.  No  riding  up  of  trochanter;  indeed,  it  is  a  little  lower  perhaps 
(adduction)  on  the  left  side.   Hyperextension  not  permitted. 

November  15, 1901^. — The  18  months  since  the  previous  examination  have 
in  greater  part  been  spent  in  the  Adirondacks.  Six  of  these  months,  lived 
at  home,  seemed  to  result  in  no  improvement,  although  patient  faithfully 
carried  out  the  Saranac  regime.  The  local  improvement  is  so  definite  that 
I  have  decided  to  permit  patient  to  discard  the  brace  and  to  walk  a  little  on 
the  affected  leg,  notwithstanding  a  definite  reaction,  both  general  and  local, 
to  2  mg.  of  tuberculin.  The  rise  in  temperature,  however,  was  very  little, 
only  to  100.5°  and  sustained  for  less  than  two  hours.  It  then  dropped 
promptly  to  normal. 

Examination. — There  is  now  for  the  first  time  no  apparent  shortening 
and  only  the  slightest  rigidity  of  the  adductor  muscles.  The  difference  in 
the  motions  of  the  right  and  left  hips  is  too  indefinite  to  be  recorded.  Patient 
has  complained  a  little  of  late  of  peculiar  feelings  in  both  hips,  somewhat 
"  rheumatic  "  in  character,  and  rather  more  pronounced  in  the  right  than 
left  hip.  During  the  past  year  she  has  had  two  or  three  rather  severe  attacks 
of  indigestion. 

March  7,  1905. — Since  last  examination  and  discarding  of  the  brace  the 
patient  has  been  getting  on  famously,  notwithstanding  a  severe  fall  on  the 
affected  hip  a  few  weeks  ago.  She  has  gained  three  to  four  pounds  in  six 
months,  which  is  a  great  deal  for  her.  Altogether  the  gain  in  weight  since 
patient  first  consulted  me  has  been  17  pounds.  The  entire  three  years,  except 
the  nights,  have  been  lived  out-of-doors.  The  crutches  are  now  discarded  and 
the  patient  is  permitted  to  walk  with  only  a  cane. 


160  OPEN-AIE  TREATMENT 

The  lessons  taught  by  the  forecited  cases,  especially  the  later  ones,  can 
hardly  fail  to  awaken  positive  enthusiasm  in  others  as  it  has  in  us.  The 
recent  observations  tinge,  however,  the  retrospect  with  regret  that  we  could 
not  have  foreseen  the  great  advantage — I  hardly  venture  to  say  necessity — 
of  the  night  out-of-doors,  as  well  as  the  day.  The  cases,  Nos.  VII,  VIII  and 
IX,  which  have  made  the  most  rapid  strides  are  those  which  have  slept  out- 
of-doors,  and,  curiously,  happen  to  be  those  which  were  not  treated  in  the 
Adirondacks  or  any  sanatorium.  These  are  the  only  patients  of  the  series 
who  have  spent  the  entire  24  hours  in  the  open.  In  one,  Case  VII,  a  month 
of  this  life  in  Virginia  sufficed  to  dissipate  completely  a  large  mass  of  tuber- 
culous glands  in  the  unoperated  side  of  the  neck.  Case  VIII,  one  of  knee- 
joint  tuberculosis,  conveys,  it  seems  to  me,  a  very  significant  lesson.  After 
a  winter  in  the  Adirondacks,  the  entire  day  out-of-doors,  and  a  gain  in 
weight  of  19  pounds,  little  if  any  local  improvement  was  demonstrable. 
It  is  quite  likely,  however,  that  we  were  unable  to  interpret  properly,  or  even 
to  discover  the  local  changes.  But  after  a  few  months,  only  three  or  four  of 
the  night  and  day  treatment  in  the  heat  of  midsummer  in  Montgomery,  Ala.. 
complete  recovery  and  almost  complete  restoration  of  function  have  taken 
place.  It  seems  to  be  a  fact  that  most  tuberculous  patients  who  are  taking 
the  out-of-doors  treatment  under  advisement  progress  more  rapidly  in  cold 
weather  than  in  hot,  and  our  patient  tells  us  that  the  weather  in  Montgomery 
was  hot,  at  times  very  hot,  while  he  was  there  in  the  open,  night  and  day. 

In  Case  IX,  three  months  of  the  24-hours-a-day  treatment,  on  the  coast 
of  Maine,  dissipated  a  mass  of  actively  inflamed  and  softened  glands  of  the 
neck,  the  skin  over  which  had  rapidly  reddened  and  thinned  during  the 
6-hours-a-day  treatment  at  the  seashore  further  south. 

I  shall  say  nothing  about  climate,  not  even  discuss  the  relative  merits  of 
localities.  I  am  merely  emphasizing  the  importance  for  some  patients  of  the 
24-hours-a-day  out-of-doors.  When  the  thermometer  registers  20°  below 
zero,  a  night  out-of-doors  is  not  an  agreeable  prospect,  and  may  be  a  difficult 
problem ;  and  so  occasionally  there  might  arise  the  question,  Is  it  better  to 
have  from  8  to  10  hours  of  the  day  in  the  open  in  a  cold  climate  or  24  hours 
in  a  more  temperate  one  ? 5  The  advantages  of  a  speedy  recovery  are  so 
evident  that  they  need  not  be  urged.  A  rapidly  growing  boy  with  tubercu- 
losis of  the  knee-joint  might  lose  a  great  deal  in  the  length  of  the  affected 

8  In  the  recital  of  Case  III,  describing  the  almost  disastrous  effects  upon  this  patient 
of  visits  from  the  North  Carolina  mountains  to  her  home,  I  may  have  conveyed  the 
impression  that  a  certain  part  of  Virginia  is  unsuitable  for  tuberculous  patients. 
But  here  the  fatigue  of  the  railroad  journey,  the  excitement  of  seeing  friends  con- 
stantly, of  living  with  relatives,  and  perhaps  numberless  little  things  may  have  been 
responsible  for  the  serious  interruptions  of  the  convalescence. 


SURGICAL  TUBERCULOSIS  161 

limb  unless  the  cure  were  rapidly  effected.  I  have  had  such  a  case  under 
observation.  The  proper  treatment  of  this  case  was  attended  with  such  diffi- 
culties that  I  consented  to  a  modified  and  less  rigorous  form  of  life  out-of- 
doors.  The  disease  made  no  progress  and  in  less  than  four  years  seemed 
cured,  but  the  boy  had,  in  the  meantime,  grown  perhaps  9  or  10  inches.  The 
affected  epiphyses  had  not  kept  pace  with  the  normal  ones  on  the  opposite 
side  and  the  boy  has  perhaps  5  inches  shortening  and  incomplete  mobility. 
If  I  could  have  foreseen  such  excessive  growth  or  had  known  the  merits  of 
the  24-hour  day,  I  must  have  insisted  upon  the  full  time  in  the  open. 

Furthermore,  the  prospect  of  years  of  treatment,  in  a  sanatorium,  or 
away  from  home,  or  at  home  on  a  roof  in  the  city,  or  simply  camping  day 
and  night  in  the  country,  is  dispiriting  and  not  readily  consented  to  by 
patients  or  friends.  But  a  few  months  or  a  year  of  such  a  life,  coupled  with 
almost  a  guarantee  of  recovery  might  be  anticipated  with  relish,  and  re- 
garded as  an  outing  combining  duty  and  pleasure  and  immeasurable  profit. 

I  shall  be  much  interested  to  learn  the  present  views  of  Dr.  Trudeau  and 
others  upon  the  relative  value  of  localities.  Several  of  my  patients  who  had 
faithfully  lived  out-of-doors,  at  home  and  abroad,  showed  the  first  positive 
signs  of  improvement,  both  general  and  local,  after  a  winter  in  the  Adiron- 
dacks.  Dr.  Trudeau,  in  one  of  his  letters  to  me  many  years  ago  concerning 
my  patients  at  Saranac,  exclaims :  "  The  more  I  go,  the  more  convinced  I 
am  that  it  is  of  little  use  merely  to  tell  people  to  live  out-of-doors.  They 
must  be  provided  with  accommodations  which  enable  them  to  live  out-of- 
doors  easily  and  comfortably.  Special  buildings  must  be  planned  and  con- 
structed for  the  purpose.  Some  day  you  will  have  to  carry  into  effect  your 
plans  for  an  infirmary  for  cases  of  surgical  tuberculosis.  These  patients 
should  sleep  out-of-doors  all  night  and  live  out-of-doors  all  day,  being  pro- 
vided with  every  comfort  and  convenience."  And  several  of  my  patients, 
after  living  awhile  at  Saranac  Lake,  have  written  to  me  that,  notwithstand- 
ing the  most  detailed  instructions  from  me  and  from  patients  who  had 
taken  the  Adirondack  cure,  they  had  not  until  then  learned  the  true  meaning 
of  the  real  life  out-of-doors.  One  should,  if  possible,  have  the  benefit  of 
the  proper  influences,  of  place,  of  people,  and,  most  important,  of  the  true 
physician,  in  order  to  acquire  the  stimulus  necessary  to  the  faithful  carry- 
ing out  of  the  treatment. 

I  should  have  the  greatest  confidence  in  the  efficacy  of  massage  in  the 
treatment  of  these  cases. 

And  as  to  the  diet,  is  it  necessary  or  wise  to  stuff  our  patients  ?  A  non- 
tuberculous  individual  is  usually  more  vigorous  if  he  is  not  overfed.  There 
is  at  least  opportunity  for  the  exercise  of  considerable  discretion  in  the  mat- 
ter of  feeding.  I  have  particularly  in  mind  a  wealthy  child,  whose  days 
12 


162  OPEX-AIE  TEEATMEXT 

were  spent  out-of-doors,  and  who  developed  tuberculous  glands,  notwith- 
standing a  huge  appetite  and  the  liberal  indulging  of  it;  and  another,  re- 
ported in  this  series,  whose  seriously  involved  knee  and  lungs  recovered 
completely,  notwithstanding  a  gradual  loss  of  weight  from  104  to  76  pounds. 

Tuberculin,  which  for  nearly  14  years  has  been  our  main  reliance  for 
diagnosis,  has  never  assisted  us  in  deciding  when  to  discontinue  fixation 
and  to  permit  use  of  the  affected  joint.  A  definite  reaction  could  probably  be 
obtained  today  in  all  of  our  u  cured  *  cases.  We  have  in  no  instance  failed 
to  get  this  reaction  when  crutches  were  about  to  be  discarded,  and  in  two 
individuals  it  was  prompter  on  release  from  the  treatment  than  at  its 
institution. 

That  most  cases  of  surgical  tuberculosis  will  recover  without  operation  if 
they  are  given  a  fair  opportunity  in  the  open  air.  I  am  convinced,  nor  should 
I  be  surprised  if  it  proved  to  be,  in  general,  an  easily  curable  disease.  My 
hardest  task  in  the  treatment  of  these  cases  has  been  to  persuade  the  rela- 
tives and  friends  and,  alas,  the  physicians  of  patients,  of  the  necessity  of 
taking  so  much  trouble,  of  instituting  a  disturbance  of  the  even  tenor  of 
the  family's  existence  or  of  involving  themselves  in  such  unanticipated  ex- 
penditure. I  have  submitted  the  pros  and  parried  the  cons  with  the  parents 
for  hours,  and  until  so  weary  of  the  battle  that  I  have  vowed  never  again 
to  misplace  so  much  energy.  But  interest  in  the  subject,  as  great  occasion- 
ally as  in  the  particular  patient,  has  usually  stimulated  a  renewal  of  the 

Unless  acquainted  with  the  lamentable  results  usually  obtained  in  the 
treatment  of  eases  such  as  these  herewith  presented,  one  can  hardly  com- 
prehend what  has  been  accomplished  by  the  open-air  treatment  of  them  and 
realize  what  assurances  it  holds  for  the  future.  How  eagerly  we  should 
welcome  an  achievement  which  properly  curtails  the  indications  for  the 
practice  of  surgery,  a  therapeutic  measure  so  crude  and  often  so  mutilative. 
In  the  huge  multitude  of  cripples  from  the  ravages  of  tuberculosis  we  find 
overwhelming  proof  of  the  inadequacy  of  past  and  present  methods  of  treat- 
ment. How  different  is  the  story  just  related.  In  not  one  instance  did  the 
disease  make  the  slightest  appreciable  advance  after  the  treatment  was  inau- 
gurated. The  restoration  of  function  is  perfect  in  all  save  one  (  Yid.  Case  II) 
and  in  this  it  is  excellent.  Had  this  patient  been  given  the  benefit  of  the 
night  as  well  as  the  day  out-of-doors  the  treatment,  begun  in  1892,  might 
have  terminated  in  one  year  or  two  instead  of  seven. 

Great  interest  is  now  being  manifested  abroad  in  the  fresh  air  treatment 
of  children  afflicted  with  surgical  tuberculosis,  but  of  its  power  for  the  cure 
of  this  disease  there  appears  to  be  only  a  meagre  conception,  the  treatment 
consisting,  as  a  rule,  of  a  very  free  circulation  of  air  through  the  wards  in 


SURGICAL  TUBERCULOSIS  163 

the  day  time,  but  not  at  night.  The  importance  of  rapid  cures  has  not  been 
emphasized,  nor  has  the  possibility  of  such  marvelously  prompt  results  as 
the  continuous  out-of-door  treatment  furnishes,  been  recognized. 

The  surgeon's  duty  is  not  done  when  he  advises  his  tuberculous  patient  to 
live  out-of-doors.  He  must,  if  the  patient's  means  permit,  and  if  other  locali- 
ties promise  decidedly  more  than  home,  send  him  away  and  entrust  him  to  a 
physician  or  companion  who  will  assume  the  responsibility  of  insuring  a 
continuous  out-of-door  life. 

Public  opinion,  which  has  compelled  the  sceptical  physician  to  transfer 
his  case  of  appendicitis  to  the  proper  surgeon,  will  soon  hold  the  surgeon 
responsible  for  bad  or  even  indifferent  results  in  tuberculous  disease  of  the 
hip,  the  knee,  the  peritonaeum. 

The  work  of  Dr.  John  W.  Brannan  and  his  associates  in  establishing  and 
conducting  the  Sea  Side  Hospital  for  Children  on  Coney  Island  deserves 
the  fullest  recognition  and  encouragement. 

The  literature  pertaining  to  this  subject  was  admirably  presented  by 
Dr.  Herbert  L.  Burrell,  in  a  discourse  at  the  annual  meeting  of  the  Massa- 
chusetts Medical  Society,  June  10,  1903. 

DISCUSSION 

We  use  Dr.  Trudeau's  preparation  and  method,  employing  two  milligrams 
to  begin  with  in  an  adult,  and  one  milligram  in  children,  increasing  the 
second  dose  to  four  milligrams.  A  third  dose  is  very  rarely  needed. 


CONDUCTION  ANAESTHESIA 


PKACTICAL  COMMENTS  ON  THE  USE  AND  ABUSE  OF  COCAINE ; 

SUGGESTED    BY    ITS    INVARIABLY    SUCCESSFUL 

EMPLOYMENT  IN  MORE  THAN  A  THOUSAND 

MINOR  SURGICAL  OPERATIONS 

WATER  AS  A  LOCAL  ANAESTHETIC ' 

While  this  article  (N.  York  If.  J.,  1885,  xlii,  294-295)  is  the  first  pub- 
lication by  Dr.  Halsted,  himself,  on  the  subject  of  cocaine  anaesthesia,  its 
republication  is  here  omitted  as  this  would  require  such  reediting  as  is  not 
deemed  expedient,  the  article  itself  having  been  written  while  Dr.  Halsted 
was  ill.  Previous  to  the  publication  of  this  article,  two  papers  had  appeared 
establishing  Dr.  Halsted's  priority  in  the  use  of  this  surgical  procedure. 
The  first  of  these  is  by  Dr.  R.  J.  Hall,  who  at  that  time  was  an  assistant  of 
Dr.  Halsted  at  the  Roosevelt  Hospital  Dispensary,  and  appears  in  the 
Neiv  York  Medical  Journal,  December  6,  1884.  The  second  paper,  entitled 
"  Hydrochlorate  of  cocaine  as  a  local  anaesthetic  in  Dental  Practice " 
(Dental  Cosmos,  Phila.,  1885,  xxvii,  208-209),  is  by  Dr.  E.  H.  Raymond, 
who  reports  the  case  of  a  Dr.  John  M.  Woodbury,  whose  very  sensitive  tooth 
was  filled  painlessly  after  typical  blocking  of  the  inferior  dental  nerve  by 
Dr.  Halsted  in  December,  1884. 

Dr.  Halsted's  first  published  statement  regarding  local  anaesthesia  by 
water-infiltration  of  the  skin  appeared  in  a  letter  dated  September  16,  1885 
(N.  York  M.  J.,  1885,  xlii,  327),  from  which  the  following  essential  state- 
ments are  quoted: 

"  1.  The  skin  can  be  completely  anaesthetized  to  any  extent  by  cutaneous 
injections  of  water. 

"  2.  I  have  at  times,  of  late,  used  water  instead  of  cocaine  in  minor 
operations  requiring  incision. 

"  3.  The  anaesthesia  seldom  oversteps  the  boundary  of  the  original 
bloodless  wheal,  but  does  not  always  vanish  just  as  soon  as  hyperaemia 
supervenes." 

The  following  letter  by  Dr.  R.  J.  Hall  is  here  quoted  in  full  from  the 
Neiv  York  Medical  Journal,  1885,  xl,  643,  because  it  is  the  first  published 
account  of  Dr.  Halsted's  early  work : 

1  Under  the  original  title  of  Dr.  Halsted's  first  publication  the  editor  has  placed  the 
collected  evidence  of  Dr.  Halsted's  pioneer  work,  including  the  discovery  of  the 
local  anaesthetic  action  of  water. 

N.  York  M.  J.,  1885,  xlii,  294-295. 

167 


168  CONDUCTION  ANAESTHESIA 

"  Htdbochxorate  of  Cocaixp. 

u  17  East  Forty-Ninth  Street,  NoTember  26,  1884. 
-  To  the  Editor  of  the  New  York  Medical  Journal: 

8 13. — Wishing  to  use  the  hydrochlorate  of  cocaine  in  some  small  opera- 
tions at  the  Roosevelt  Hospital  One-Door  Department,  I  made  same  experi- 
ments on  myself  to  determine  the  best  mode  of  using  it  The  preparation 
was  a  4  per  cent  solution  made  by  Parke,  Davis  &  Co.  Injecting  subcu- 
taneously  six  minims  on  the  dorsal  surface  of  the  forearm,  at  the  junctions 
of  the  middle  and  upper  thirds,  near  the  ulnar  border,  caused  complete  loss 
of  sensation  oxer  an  area  extending  downward  as  far  as  the  lover  end  of  the 
ulna,  from  three  quarters  of  an  inch  to  an  inch  wide  above,  and  half  an  inch 
vide  below,  obviously  following  the  distribution  of  a  cutaneous  branch  of 
the  ulnar  nerve.  There  was  no  diminution  of  sensibility  above  the  point  at 
which  the  needle  was  introduced.  A  number  of  subsequent  experiments 
showed  that  the  anaesthesia  extended  over  the  region  supplied  by  the  cutane- 
ous nerves  near  or  into  which  the  injection  was  made.  Thus,  in  a  number 
of  experiments  made  by  Dr.  Halsted  and  myself,  we  have  found  that,  in- 
jected subcutaneously  into  the  leg  or  forearm,  not  in  the  neighborhood  of 
any  large  nerve-trunk,  it  will  cause  anaesthesia  for  a  distance  of  two  or 
three  inches  below  the  point  of  injection.  An  injection  into  the  musculo- 
cutaneous nerve  of  the  leg,  at  the  point  where  it  pierces  the  deep  fascia, 
caused  anaesthesia  over  all  that  portion  of  the  leg  and  foot  supplied  by  this 
nerve.  An  injection  of  eight  minims  into  my  left  ulnar  nerve  at  the  elbow 
had  no  effect  An  injection  of  thirty-two  minims  into  the  right  ulnar  nerve 
at  the  elbow  caused,  in  two  or  three  minutes,  numbness  and  tingling  down 
the  forearm  and  little  finger,  and  in  five  or  six  minutes  anaesthesia  extend- 
ing down  the  ulnar  border  of  the  forearm  and  hand  and  over  the  little  finger, 
with  mnch  reduction  of  the  sensibility  on  the  ulnar  border  of  the  ring-finger. 
There  was  an  anaesthetic  area  over  the  olecranon  and  the  posterior  surface 
of  the  external  condyle,  which  we  should  not  expect  to  be  supplied  by  the 
ulnar  nerve.  There  was  no  apparent  diminution  of  muscular  power,  and 
no  anaesthesia  of  the  skin  at  the  point  where  the  injection  was  given.  We 
have  noticed  that,  when  the  needle  is  thrust  into  the  deeper  layers  of  the 
subcutaneous  connective  tissue,  there  is  usually  no  loss  of  sensibility  at  the 
point  where  the  needle  was  introduced. 

■  With  the  anaesthesia,  marked  constitutional  symptoms  appeared ;  about 
six  minutes  after  the  injection  there  was  giddiness,  at  first  slight,  then  well 
marked,  so  that  I  could  not  walk  without  staggering;  and  finally  there  was 
severe  nausea,  which  would  have  been  mnch  worse,  I  think,  had  not  the 
stomach  been  empty.  At  the  same  time,  the  skin  was  covered  with  cold  per- 
spiration, and  the  pupils  were  dilated.  The  nausea  passed  off,  with  the  local 
anaesthesia,  in  about  twenty  minutes,  leaving  some  dinJnesB  far  an  hour 
or  so  longer. 

'*  The  same  evening  Dr.  Halsted  removed  a  small  congenital  cystic  tumor, 
situated  directly  over  the  outer  third  of  the  left  supraorbital  ridge,  and 
believed  to  be  a  meningocele,  the  communication  of  which  with  the  cranial 


CONDUCTION  ANAESTHESIA  169 

cavity  had  been  shut  off.  Nineteen  minims  of  the  4  per  cent  solution  were 
given  hypodermically  in  divided  doses,  one  external  to  the  tumor,  and  the 
others  close  to  the  supraorbital  notch.  In  about  five  minutes  the  anaesthesia 
was  complete.  The  incision  through  the  skin  and  the  earlier  steps  of  the 
operation  were  not  felt  at  all,  but,  in  consequence  of  the  close  adhesions  of 
the  sac  and  its  extensive  prolongations,  especially  into  the  upper  lid,  the 
operation  was  somewhat  protracted,  and  the  anaesthesia  had  passed  off  to 
a  considerable  extent  before  it  was  completed.  I  was  informed  of  a  case, 
occurring  on  the  same  day,  in  which  cocaine  was  injected,  preparatory  to 
performing  a  small  plastic  operation,  in  the  same  region,  but  no  anaesthesia 
of  the  field  of  operation  was  produced.  On  inquiry,  I  was  told  that  the  in- 
jections had  been  given  above  the  point  where  the  incisions  were  to  be  made. 

"  This  afternoon,  having  occasion  to  have  the  left  first  upper  incisor  tooth 
filled,  and  finding  that  the  dentine  was  extremely  sensitive,  I  induced 
Dr.  Nash,  of  No.  31  West  Thirty-First  Street,  to  try  the  effects  of  cocaine. 
The  needle  was  passed  through  the  mucous  membrane  of  the  mouth  to  a 
point  as  close  as  possible  to  the  infraorbital  foramen,  and  eight  minims  were 
injected.  In  two  minutes  there  was  complete  anaesthesia  of  the  left  half 
of  the  upper  lip  and  of  the  cheek  somewhat  beyond  the  angle  of  the  mouth 
(as  I  was  in  the  dentist's  chair,  I  could  not  determine  the  exact  limits), 
involving  both  the  cutaneous  and  the  mucous  surfaces ;  also  of  the  left  side 
of  the  lower  border  of  the  septum  nasi  and  of  the  anterior  surface  and  lower 
border  of  the  gums,  extending  from  the  median  line  to  the  first  molar  tooth. 
Forcing  the  teeth  apart  with  a  wedge  caused  no  pain  except  when  the  wedge 
impinged  on  the  unaffected  mucous  membrane  of  the  posterior  surface  of 
the  gums.  Dr.  Nash  was  then  able  to  scrape  out  the  cavity  in  the  tooth, 
which  had  previously  been  so  exquisitely  sensitive,  and  to  fill  it,  without  my 
experiencing  any  sensation  whatever.  The  anaesthesia  was  complete  until 
twenty-six  minutes  after  the  injection,  and  sensibility  was  much  diminished 
for  ten  or  fifteen  minutes  longer.  Piercing  the  mucous  membrane  with  the 
needle  caused  pain  like  the  prick  of  a  pin,  but  its  subsequent  introduction 
until  it  struck  the  bone  and  the  injection  of  the  solution  were  not  felt.  In 
the  same  way,  the  introduction  of  the  needle  into  the  ulnar  nerve  caused 
quite  severe  pain,  with  tingling  down  the  little  finger,  but  the  injection  of 
the  fluid  gave  rise  to  no  sensation.  In  the  experiment  on  teeth,  it  surprised 
that  the  incisor  tooth  should  be  rendered  insensitive,  as  the  anterior-superior 
dental  nerve  is  given  off  in  the  infraorbital  canal.  I  can  only  suppose  that 
the  effect  extends  some  distance  along  the  nerve  centrally,  or  that  the  fluid 
travels  along  the  sheath  of  the  nerve  into  the  canal. 

"  We  have  already  used  this  mode  of  administration  successfully  in  a 
number  of  cases  in  the  Eoosevelt  Hospital  Out-Door  Department,  and  it  is 
obvious  that  when  the  limits  of  safety  have  been  determined  it  may  find 
very  wide  application.  For  instance,  in  addition  to  the  usual  application 
to  the  conjunctiva,  in  operations  on  the  eye,  an  injection  into  the  orbit,  in 
the  neighborhood  of  the  ciliary  nerves,  would  doubtless  diminish  the  lia- 
bility to  a  very  grave  accident,  which  I  understand,  has  already  occurred 
several  times  in  the  city — namely,  in  extrusion  of  the  lens,  from  blepharo- 


170  CONDUCTION  ANAESTHESIA 

spasm,  occurring  during  iridectomy  performed  with  the  aid  of  cocaine. 
We  have  injected  twenty  minims  a  number  of  times,  without  causing  any 
constitutional  symptoms. 

"  Very  truly  yours, 

«  E.  J.  Hall,  M.  D. 

"Postscript,  December  1st.  Since  the  foregoing  was  written  we  have 
made  some  additional  experiments  which  seem  of  interest.  Dr.  Halsted 
gave  Mr.  Locke,  a  medical  student,  an  injection  of  nine  minims,  trying  to 
reach  with  the  point  of  the  needle  the  inferior  dental  nerve  where  it  enters 
the  dental  canal.  In  from  four  to  six  minutes  there  was  complete  anaes- 
thesia of  the  tongue,  on  the  side  where  the  injection  had  been  given,  extend- 
ing to  the  median  line  and  backward  to  the  base  as  far  as  could  be  reached 
with  a  pointed  instrument.  There  was  further  complete  anaesthesia  of  the 
gums,  anteriorly  and  posteriorly,  to  the  median  line,  and  all  the  teeth  on 
that  side  were  insensitive  to  blows.  The  soft  palate  and  uvula,  on  the  same 
side,  were  anaemic  and  quite  insensitive.  Mr.  Locke  thought  also  that  there 
was  some  diminution  of  sensibility  in  the  domain  of  the  auriculo-temporal 
nerve. 

"  In  four  or  five  other  cases  where  the  injection  was  made  in  the  same 
way,  from  fifteen  to  twenty  minims  being  used,  the  fluid  seemed  to  have 
come  nearer  the  lingual  than  the  inferior  dental.  In  all,  the  tongue  was 
affected  sooner  than  the  gums ;  the  anaesthesia  extended  as  far  back  as  the 
epiglottis,  and  the  sense  of  taste  was  abolished  on  the  affected  side ;  and  the 
posterior  surface  of  the  gums  was  earlier  and  more  completely  anaesthetized 
than  the  anterior. 

"  This  evening  Dr.  Halsted  gave  me  an  injection  of  seventeen  minims, 
the  needle  being  introduced  along  the  internal  surface  of  the  left  ramus 
until  it  touched  the  inferior  dental  nerve,  causing  a  sharp  twinge  along  the 
whole  line  of  the  lower  teeth.  In  three  minutes  there  was  numbness  and 
tingling  of  the.  skin,  extending  from  the  angle  of  the  mouth  to  the  median 
line,  and  also  of  the  left  border  of  the  tongue.  In  six  minutes  there  was 
complete  anaesthesia  of  the  left  half  of  the  lower  lip,  on  both  the  cutaneous 
and  mucous  surfaces,  extending  from  the  median  line  to  the  angle  of  the 
mouth  and  downward  to  the  inferior  border  of  the  jaw.  A  pin  thrust  com- 
pletely through  the  lip  caused  no  sensation  whatever.  There  was  also  com- 
plete anaesthesia  of  the  posterior  surface  of  the  gums  and  of  the  lower  teeth 
on  the  left  side,  exactly  to  the  median  line ;  hard  blows  upon  the  teeth  with 
the  back  of  a  knife  caused  no  sensation.  The  anterior  surface  of  the  gums  was 
anaesthetic  only  from  the  median  line  to  the  first  bicuspid.  There  was  a 
small  area  of  complete  anaesthesia  about  the  middle  third  of  the  left  border 
of  the  tongue,  not  more  than  an  inch  in  diameter.  A  slight  return  of  sensa- 
tion began  twenty-five  minutes  after  the  injection  and  five  minutes  later  no 
complete  anaesthesia  remained  anywhere.  I  should  mention  that  fifteen 
to  twenty  minims  in  this  region  caused,  in  two  or  three  cases,  slight  consti- 
tutional symptoms  similar  to  those  previously  described." 


CONDUCTION  ANAESTHESIA  171 

The  following  article  by  Dr.  E.  H.  Raymond  is  here  quoted  from  the 
Dental  Cosmos,  Phila.,  1885,  xxvii,  208-209,  because  it  is  the  second  pub- 
lished account  of  Dr.  Halsted's  early  work : 

"  Hydeochlorate  of  Cocaixe  as  a  Local  Anaesthetic  in  Dextal 

SUEGERT 

"  The  New  York  Odontological  Society  held  a  regular  monthly  meeting 
at  the  house  of  Dr.  W.  E.  Hoag,  No.  13  East  Forty-Third  Street,  January  20, 
1885. 

"  The  President,  Dr.  William  Jaryie,  in  the  chair. 

"President  Jamie. — Gentlemen,  as  you  all  know  the  experiments  that 
haye  been  and  are  in  the  course  of  being  made  with  cocaine  are  attracting  a 
great  deal  of  attention.  Dr.  Raymond  has  been  studying  this  matter  re- 
cently, and  he  will  giye  us  his  experiences. 

**  Dr.  E.  H.  Raymond. — This  brings  me  to  the  citation  of  cases  of  success- 
ful practical  experimentation,  which  demonstrates  this  fact,  by  bringing 
the  agent  in  contact  with  the  nerve  trunk  you  will  get  partial  if  not  total 
insensibility  throughout  its  ramifications.  Early  in  December  while  attend- 
ing Dr.  John  M.  Woodbury  of  this  city,  professionally,  the  subject  of  cocaine 
was  mentioned.  He  informed  me  that  he  and  several  of  his  friends  had  used 
it  in  minor  surgical  operations  by  injecting  it  on  the  nerve  supplying  sen- 
sation to  the  part  to  be  operated  on.  As  he  had  a  yery  sensitive  cavity  to 
be  filled  in  a  molar,  I  suggested  the  idea  of  his  being  injected  with  the 
cocaine,  so  that  we  might  test  the  drug  and  its  effect  upon  the  tooth.  He 
willingly  assented.  We  accordingly  went  to  the  office  of  his  friend, 
Dr.  Halsted,  who  injected  the  drug  with  the  following  result : 

Case  I. — Dr.  W. ;  cavity  on  the  posterior  surface  of  the  right  inferior 
first  molar :  excessive  sensibility  on  touching  it.  Caries  had  not  caused  much 
loss  of  the  dentine  covering  the  pulp.  That  organ  was  well  protected  and 
in  a  normal  condition.  The  syringe  was  charged  with  thirteen  minims  of  a 
4  per  cent  solution  of  cocaine,  and  the  needle-point  directed  on  a  line  extend- 
ing about  midway  between  the  angle  and  the  coronoid  process  of  the  inferior 
maxillary,  passing  through  the  internal  pterygoid  muscle.  The  finger  being 
placed  upon  the  internal  oblique  line  as  a  guide,  the  syringe-needle  was 
carried  along  the  inner  surface  of  the  ramus  until  it  reached  the  nerve  as 
it  enters  the  inferior  dental  foramen.  A  "  tingling  "  sensation  was  produced 
in  the  bicuspids  and  incisors  when  the  syringe  was  discharged.  In  three 
minutes  the  tongue  began  to  feel  thick  and  numb  on  the  right  side.  In  seven 
minutes  there  was  almost  complete  anaesthesia  of  the  right  half  of  the 
tongue  and  the  gums  around  the  inferior  teeth.  The  excavator  being  applied 
to  the  cavity  which  was  previously  so  tender,  no  sensation  whatever  was  felt 
by  the  patient.  I  then  used  the  engine  with  perfect  freedom,  and  prepared 
the  cavity  for  filling  without  any  discomfort  to  him.  Although  there  was 
just  a  slight  degree  of  sensibility  in  the  bottom  of  the  cavity,  he  said  it 
amounted  to  nothing  comparatively ;  he  was  just  conscious  that  the  instru- 
ment was  there.  The  gustatory  nerve,  which  lies  near  the  inferior  dental  at 
the  point  injected,  accounts  for  the  tongue  being  anaesthetized.  As  the  gus- 
tatory was  not  touched,  this  shows  that  it  is  not  necessary  for  the  needle  to 


172  CONDUCTION  ANAESTHESIA 

penetrate  the  nerve-substance.  The  cervical  portion  of  the  cuspid  on  the 
left  side  was  very  painful  to  touch,  owing  to  denudation  of  the  soft  tissues 
that  covered  it;  but,  while  operating  on  the  side  injected,  the  cuspid,  al- 
though being  in  the  same  condition  as  the  other,  could  be  rubbed  with  a 
steel  instrument  without  the  slightest  manifestation  of  pain.  The  anaes- 
thesia lasted  for  about  twenty-eight  minutes,  when  normal  sensibility  re- 
turned. That  evening  at  dinner  there  was  some  stiffness  and  a  slight 
soreness  in  the  muscles  while  masticating  on  the  right  side.  The  next  morn- 
ing there  were  no  symptoms  indicating  that  he  had  submitted  to  any  un- 
usual treatment." 

Two  previously  unpublished  letters  of  Dr.  Halsted  to  Dr.  C.  E.  Kells 
contain  further  description  of  his  work  and  are  here  quoted : 

"  March  29,  1920. 
"Dr.  C.  Edmund  Kells,  1237  Maison  Blanche,  New  Orleans,  La.: 

"  Deak  De.  Kells. — I  am  very  appreciative  of  Dr.  Matas'  kindness  in 
telling  you  of  our  early  work  with  cocaine  and  take  pleasure  in  complying 
with  your  polite  request  for  further  details. 

"  Dr.  Eichard  Hall  died  many  years  ago  in  Los  Angeles  or  Santa  Barbara. 
Hall  and  I  were  studying  in  Vienna  in  1879  and  1880,  and  later  were  inti- 
mately associated  in  surgical  work  at  the  Koosevelt  Hospital  and  in  its 
Out-Patient  Department,  he  being  my  first  assistant,  Frank  Hartley,  the 
second,  and  Frank  Markoe,  the  third.  Dr.  George  Brewer  of  New  York 
was  also  an  accomplished  member  of  my  staff  in  this  dispensary. 

"  Within  a  week  or  two,  at  most,  of  the  arrival  in  this  country  of  Roller's 
first  paper  announcing  the  anaesthetic  effect  of  cocaine  on  the  conjunctiva 
we  began  active  experimentation  with  this  drug,  hoping  that  it  might  prove 
of  use  in  general  surgery.  By  "  we  "  I  mean  twenty-five  or  thirty  students 
of  the  College  of  Physicians  and  Surgeons  (Columbia),  all  having  the  B.  A. 
degree,  who  registered  with  me  as  their  preceptor.  At  the  evening  quizzes 
we  began  our  injections  into  nerves,  almost  all  of  the  accessible  nerves  being 
tested — the  inferior  dental  with  the  rest. 

"  Dr.  Thomas  A.  McBride,  a  remarkably  gifted  physician  with  a  large 
consulting  practice,  referred  to  me,  in  the  winter  of  1884  and  1885,  the 
wife  of  a  wealthy  and  prominent  citizen.  She  was  a  sufferer  from  trigeminal 
neuralgia,  the  pain  being  pretty  well  confined  to  the  region  supplied  by  the 
third  branch.  I  decided  to  perform  the  Paravicini  operation  under  local 
anaesthesia  and  designed  a  very  broad  clamp  with  which  to  seize  the  nerve. 
The  purpose  of  the  unusual  breadth  of  the  instrument  was  to  insure  the 
excision  of  a  long  piece  of  the  inferior  dental  nerve. 

"  The  operation  was  performed  in  a  bedroom  of  my  house,  the  patient 
being  assured  that  she  could  return  home  the  same  afternoon.  I  was  assisted 
by  Dr.  Eichard  Hall  and  Dr.  Frank  Hartley.  The  nerve  having  been  satis- 
factorily anaesthetized  central  to  the  inferior  dental  foramen  with  a  4  per 
cent  solution  of  muriate  of  cocaine,  was  exposed  and  seized  with  the  broad 
clamp  without  great  difficulty.  With  a  scissors  I  divided  the  nerve  at  the 
distal  edge  of  the  clamp.  Then,  guided  only  by  the  clamp  and  a  finger, 
I  made  a  snip  with  the  scissors,  in  the  deep  hole,  through  the  nerve  at  the 
central  edge  of  the  clamp.    Thereupon  there  was  a  great  gush  of  arterial 


CONDUCTION  ANAESTHESIA  173 

blood — so  great  I  thought  that  the  internal  maxillary  artery  must  have  been 
cut.  The  patient  was  in  danger  for  a  moment  of  being  suffocated  with  blood. 
By  forcible  packing  with  iodoform  gauze  the  haemorrhage  was  stopped,  but 
such  pressure  was  made  by  the  packing  that  I  feared  extensive  sloughing 
of  the  soft  parts  might  ensue.  Confidently  expecting  a  recurrence  of  the 
bleeding,  I  hastily  summoned  two  trained  nurses  from  the  Presbyterian  Hos- 
pital and  had  the  patient  put  to  bed  in  my  house.  In  a  day  or  two  she  was 
transferred  to  the  Presbyterian  Hospital.  There  was  no  recurrence  of  the 
bleeding. 

"  About  the  eighth  day  after  operation  and  with  considerable  apprehen- 
sion I  cautiously  removed  the  gauze  packing.  The  patient  recovered  without 
a  complication  of  any  kind. 

*  Strange  to  say,  I  did  not  know  that  Hall  had  reported  this  case  until  in 
1914  at  a  meeting  of  the  Deutsche  Gesellschaft  fur  Chirurgie  Professor 
Rehn,  the  President  of  the  Congress,  referred  to  it  in  the  course  of  a  dis- 
cussion. Prom  him  I  obtained  the  reference  to  Hall's  paper.  I  believe  that 
Braun  mentions  it  in  his  book  on  local  anaesthesia. 

"  Hall  was  appointed  professor  of  anatomy  at  the  Columbia  Medical 
School,  but  on  account  of  ill  health  he  soon  resigned.  He  became  a  success- 
ful and  highly  esteemed  practitioner  of  surgery  in  Santa  Barbara  or  Los 
Angeles.  Dr.  George  Woolsey  and  Dr.  Lucius  Hotchkiss  and  other  students 
of  mine  in  New  York  could  tell  you  something  of  our  early  experiments  and 
operations  with  local  anaesthesia. 

"  I  published  at  the  time  a  few  little  paragraphs  on  the  subject  in  the 
New  York  Medical  Journal.  One  of  these  was  to  call  attention  to  the  fact 
that  one  could  produce  local  anaesthesia  with  injections  of  water.  We  soon 
discovered  that  very  dilute  solutions  of  cocaine  sufficed,  and  in  the  first 
years  of  The  Johns  Hopkins  Hospital  I  made  extensive  use  of  local  anaes- 
thesia with  these  very  mild  solutions — as  weak  sometimes  as  one  to  ten 
thousand. 

"  Already  in  1884  I  had  noted  the  effect  of  anaemia  on  the  anaesthetized 
parts,  and  emphasized  the  importance  of  distending  the  tissues  until  they 
were  blanched.  I  made  use  of  the  constricting  rubber  bandage  on  the  limbs 
and  of  heavy  rubber  rings  on  the  fingers  in  order  to  intensify  and  prolong 
the  action  of  the  drug.  When  small  veins  were  accidently  injected  we  ob- 
served the  production  of  urticaria-like  wheals. 

"  In  the  fall  of  1885  I  had  a  few  amusing  experiences  with  the  dentists 
in  Vienna.  Having  occasion  to  consult  Dr.  Thomas,  a  famous  '  American 
dentist/  with  spacious  offices  in  the  '  Graben/  I  demonstrated  to  him  the 
effects  of  injecting  the  inferior  dental  nerve.  His  first  assistant  was  so  im- 
pressed that  he  requested  me  to  inject  his  nerve,  and  thereupon  asked 
Dr.  Thomas  to  pull  one  or  two  roots  and  fill  a  tooth.  Professor  Anton 
Wolfler,  the  first  assistant  of  Billroth,  published  during  this  visit  of  mine 
to  Vienna  a  brief  note  on  the  subject  of  cocaine  anaesthesia  in  one  of  the 
Vienna  morning  papers,  based  on  a  demonstration  which  I  had  given  him 
a  day  or  two  before  of  our  method  of  using  it  for  surgical  operations.  Prior 
to  this  demonstration  he  had  convinced  himself  by  experimentation  that 
cocaine  would  not  produce  anaesthesia  except  on  the  surface  of  mucous 
membranes — that  it  was  useless  when  injected  into  the  tissues. 


174  CONDUCTION  ANAESTHESIA 

"  I  beg  that  you  will  pardon  me  for  indulging  in  such  a  lengthy 
reminiscence. 

"  Will  you  give  my  kind  regards  to  Dr.  Matas. 

"  Very  truly  yours, 

"  Wm.  S.  Halsted." 

"  Baltimore,  October  26,  1920. 
"  Dr.  C.  Edmund  Kells,  1237  Maison  Blanche,  New  Orleans,  La.  : 

"  Deae  Dr.  Kells. — In  reply  to  your  question  I  may  say  that  Koller 
was  the  first  to  inject  the  infraorbital  nerve,  but  my  experiments  on  nerve 
blocking  antedate  his.  I  practised  blocking  almost  every  nerve  which  we 
thought  could  be  reached  with  the  needle  (roots  of  the  brachial  plexus, 
sciatic,  and  particularly  the  subcutaneous  nerves)  and  performed  many 
minor  and  some  major  operations  with  local  anaesthesia  (excision  of  axil- 
lary glands,  resection  of  elbow,  amputations,  etc.). 
"  With  kind  regards,  I  am, 

"  Very  truly  yours, 

"  Wm.  S.  Halsted." 

The  following  paragraphs  from  a  letter  of  Dr.  Halsted  to  Dr.  Matas  con- 
tain further  statements  of  Dr.  Halsted  on  local  anaesthesia : 

"  May  30,  1921. 
"Dr.  Rudolph  Matas,  2255  St.  Charles  Ave.,  New  Orleans,  La.: 

"  My  dear  Matas. — You  can  well  believe  that  after  discovering  the  anaes- 
thetic properties  of  water — which  I  attributed  largely  to  anaemia  produced 
by  it — that  I  should  have  immediately  experimented  with  very  dilute  solu- 
tions of  cocaine.  The  intradermal  injections  were  made  with  the  intention 
of  producing  anaemia,  and  we  were  guided  then  as  today  in  making  our 
incisions  by  the  anaemic  appearance  of  the  skin  distended  by  the  injected 
fluid. 

"  Ever  yours, 

"  Wm.  S.  Halsted. 

"P.  S.  One  of  the  major  operations  performed  by  me  under  cocaine 
anaesthesia  during  the  winter  of  1884-1885  was  the  freeing  of  the  cords  and 
nerves  of  the  brachial  plexus  after  injection  of  the  roots  of  this  plexus.  This 
operation  was  performed  in  a  large  tent  which  I  built  on  the  grounds  of 
Bellevue  Hospital,  having  found  it  impossible  to  carry  out  antiseptic  pre- 
cautions in  the  general  amphitheatre  of  Bellevue  where  the  numerous  anti- 
Lister  surgeons  dominated  and  predominated." 

The  following  extract  from  a  letter  of  Dr.  Rudolph  Matas  of  New  Or- 
leans to  Dr.  Willard  Bartlett  is  quoted  because  it  clearly  states  the  judgment 
of  an  eminent  American  surgeon  and  authority,  who  made  a  thorough  study 
of  the  question  of  priority  in  the  introduction  of  conduction  surgical  anaes- 
thesia. Dr.  Matas,  a  lover  of  justice  and  historic  accuracy,  considers  that 
"  Dr.  Halsted's  just  right  to  recognition  as  the  first  to  discover  and  apply 
the  facts  that  are  at  the  present  time  fundamental  in  regard  to  local  and 


CONDUCTION  ANAESTHESIA  175 

regional  anaesthesia,  nerve  blocking,  or  socalled  conduction  anaesthesia 
(Leitungs  Anesthesia)  should  be  given  the  recognition  they  deserve,  espe- 
cially from  his  American  colleagues."  Dr.  Matas'  communication  is  in- 
cluded in  Dr.  Bartlett's  Presidential  Address  before  the  Southern  Surgical 
and  Gynecological  Association,  "  An  estimate  of  the  value  of  local  anaes- 
thesia in  the  surgery  of  today  "  (Tr.  South.  Surg.  &  Gynec.  Ass.,  Phila., 
1920,  xxxiii,  2-3) : 

"  Dr.  Halsted's  work  began  almost  immediately  after  Roller  had  made 
his  epochal  announcement  of  the  anaesthetic  practice  of  cocaine  on  the  eye, 
at  the  Heidelberg  Ophthalmologic  Congress  in  September,  1884.  He  set 
to  work  at  once  at  the  Eoosevelt  Hospital,  and  before  December,  1884,  had 
discovered  at  least  three,  if  not  four,  fundamental  facts,  which  he  demon- 
strated experimentally  and  clinically,  in  which  he  antedated  all  other 
investigators. 

"The  discoveries  are:  (1)  The  intradermal  as  distinguished  from  the 
subcutaneous  method  of  infiltration;  (2)  the  value  of  water  as  a  local 
anaesthetic  and  of  the  efficiency  of  very  dilute  analgesic  solutions,  in  which 
he  antedated  Schleich  by  at  least  four  years;  (3)  the  neuroregional  method, 
or  regional  anaesthesia  by  nerve  blocking,  which  he  clearly  demonstrated  by 
blocking  the  inferior  dental  at  the  spine  of  Spix,  and  thus  obtaining  com- 
plete anaesthesia  of  the  teeth  of  the  lower  jaw,  which  permitted  the  pain- 
less extraction  of  the  teeth.  See  Hall's  letter  in  the  New  York  Medical 
Journal  for  December  6,  1884,  and  Baymond's  report,  New  York  Odon- 
tological  Society,  1885  (The  Dental  Cosmos,  Phila.,  1885,  xxvii,  208),  who 
describe  a  painless  operation  on  the  teeth,  in  December,  1884,  after  Halsted 
had  injected  the  inferior  dental  at  its  entrance  into  the  inferior  dental  canal. 
On  all  these  points  there  can  be  no  question  of  his  right  to  priority,  and  I 
also  believe  that  he  was  the  first  to  note;  (4)  the  prolongation  of  the  anaes- 
thetic action  of  the  drug  by  circular  constriction  and  retardation  of  the 
circulation  in  the  infiltrated  area." 

The  following  comprehensive  bibliography,  which  was  prepared  by 
Dr.  Eudolph  Matas  of  New  Orleans,  so  clearly  presents  the  evidence  of  the 
priority  of  Dr.  Halsted's  work  that  it  is  deemed  important  to  include  it.  The 
editor  has  added  several  references. 

1.  Koller,   K.    Vorlaufige    Mitteilung    iiber   local   Anasthesirung   im    Auge.    XVI. 

Ophthalmologen  Kongress.   Heidelberg,  Sept.,  1884. 

2.  Koller,  K.    Ueber  Verwendung  des  Cocain  zur  Anasthesirung  am  Auge.    Wien. 

med.  Woch,  1884,  1276-1278;  1309-1311. 

Also:  Translated  into  English  by  H.  Knapp  and  published  in,  "Cocaine 
and  its  use  in  ophthalmic  and  general  surgery "  by  Hermann  Jakob 
Knapp,  M.  D.,  New  York  &  London,  G.  P.  Putnam's  Sons,  1885,  pages  1-9. 

3.  Hall,  R.  J.  Hydrochlorate  of  cocaine.    A  letter  to  the  Editor  of  the  New  York 

Medical  Journal,  December  6,  1884.   N.  York  M.  J.,  1884,  xl,  643-644. 

(In  this  is  the  first  account  of  Halsted's  experimental  and  clinical  demonstrations 
In  dental  and  oral  practice  following  a  few  weeks  after  Koller's  publication  in  the 
Wien.  med.  Woch.,  1SS4.) 


176  CONDUCTION  ANAESTHESIA 

4.  "  The  new  local  anaesthetic."    An  editorial  in  the  New  York  Medical  Journal, 

December  6,  1S84,  xl,  641. 

(In  this  editorial  Halsted's  and  Hall's  first  experiences  in  regional  anaesthesia 
and  nerve  blocking  are  related  and  fully  credited.) 

5.  Raymond,  E.  H.    Hydrochlorate  of   cocaine   aa  a  local  anaesthetic  in  dental 

surgery.   Tr.  N.  York  Odontological  Soc,  1885.    (Philadelphia,  1886.) 

Also:   Dental  Cosmos,  Phila.,  1885,  xxvii,  208-209. 

(In  this  an  account  is  given  of  the  case  of  Dr.  Woodbury  who  had  a  very  sensitive 
cavity  filled  painlessly  after  a  typical  blocking  of  the  inferior  dental  nerve  by  Dr. 
W.  S.  Halsted.  This  was  done  in  December  1884,  a  little  over  two  months  after 
Koller's  first  publication  had  reached  this  country.) 

6.  Halsted,  W.  S.   Practical  comments  on  the  use  and  abuse  of  cocaine,  suggested 

by  its  invariably  successful  employment  in  more  than  1000  minor  surgical 
operations.   N.  York  M.  J.,  1885,  xlii,  294-295. 

(This  is  only  the  first  part  of  a  paper  which  was  intended  to  review  Dr.  Halsted's 
work  from  October.  1884,  to  the  date  of  publication,  but  was  never  completed  on 
account  of  Dr.  Halsted's  illness.) 

7.  Halsted,  W.  S.   Water  as  a  local  anaesthetic.   A  letter  to  the  Editor.   N.  York 

M.  J.,  1885,  xlii,  327.    September  19th,  1885. 

8.  Knapp,  H.  J.   Cocaine  and  its  use  in  ophthalmic  and  general  surgery. 

In:  Cocaine  and  its  use  in  ophthalmic  and  general  surgery,  by  Hermann 
Jakob  Knapp,  M.D.,  New  York  &  London,  G.  P.  Putnam's  Sons,  1885, 
pages  27-28. 

9.  Hall,  R.  J.   Cocaine  in  general  surgery. 

In:  Cocaine  and  its  use  in  ophthalmic  and  general  surgery,  by  Hermann 
Jakob  Knapp,  M.  D.,  New  York  &  London,  G.  P.  Putnam's  Sons,  1885,  pages 
76-77. 

10.  Dawbarn,  R.  H.  M.    Water  as  a  local  anaesthetic.   Its  discovery  American  and 

not  German.    Med.  Rec,  N.  Y.,  1891,  xl,  613. 

(Refers  to  Halsted's  discoveries  in  local  and  regional  anaesthesia.) 

11.  Matas,  R.  Local  and  regional  anaesthesia  with  cocaine  and  other  analgesic  drugs. 

The  latest  methods.  Report  of  the  chairman  of  the  Section  of  Surgery  of  the 
Louisiana  State  Medical  Society.  Proc.  Louisiana  State  Med.  Soc,  New 
Orleans,  1900,  April  19-21.  The  growing  importance  and  value  of  local  and 
regional  anaesthesia  in  minor  and  major  surgery.  Trans.  Louisiana  State 
Med.  Soc,  21st  Annual  Session,  New  Orleans,  1900,  page  329. 

(In  this  contribution  the  several  discoveries  of  Dr.  Halsted  in  the  domain  of 
local  and  regional  anaesthesia  are  duly  credited  and  special  reference  to  his  pre- 
cedence over  all  other  investigators  in  establishing  and  demonstrating  the  principle 
of  nerve  blocking,  is  fully  stated  (see  pp.  9,  10.) 

12.  Matas,  R.  Local  and  regional  anaesthesia  with  cocaine  and  other  analgesic  drugs, 

including  the  subarachnoid  method,  as  applied  in  general  surgical  practice. 
(Illustrated.)   Phila.  M.  J.,  1900,  vi,  820-843.   (See  page  822.) 

(In  this  paper  full  credit  is  given  to  Halsted  and  Hall  for  the  first  demonstration 
of  neural  cocainization  "  nerve  blocking.") 

13.  Braun,  H.  Die  Lokalaniisthesie,  Leipzig,  1905,  page  77;  page  405,  bibliography, 

reference  to  Hall's  paper  on  Dr.  Halsted's  injection  of  the  inferior  dental 
nerve. 

14.  Braun,  H.   Die  lokal  Aniisthesie,  Leipzig,  1907,  i,  8,  pp.  425. 

(A  recognized  German  authority  in  local  and  regional  anaesthesia  credits  Halsted 
with  the  first  clinical  application  of  nerve  blocking  in  dental  practice.  (7th  chapter, 
p.  77 ;  and  again  In  the  !»th  chapter,  p.  178 ;  and  again  in  the  11th  chapter,  p.  294.) 
While  giving  Halsted  full  credit  throughout  as  the  first  discoverer  and  demonstrator 
of  the  principle  of  nerve  blocking,  he  erroneously  quotes  the  year  of  the  discovery  as 
1885,  whereas  Dr.  Halsted's  experiments  began  in  the  fall  of  1S84,  shortly  after 
Koller's  account,  as  shown  in  Hall's  letter  to  the  New  York  Medical  Journal, 
December  6,  1884.) 


CONDUCTION  ANAESTHESIA  177 

15.  Allen,  C.  W.    Local  anaesthesia,  by  Carroll  W.  Allen,  with  an  introduction  by 

Rudolph  Matas,  Phila.  &  London,  W.  B.  Saunders  Company,  1914,  625  p. 

including  255  ill.    (See  pages  3,  5,  150-152.) 
Also:    Local  anaesthesia,  2nd.  edition,  1918.    (See  pages  158-160.) 
(Gives  credit  to  Dr.  Halsted  for  his  several  discoveries  quoting  from  Dr.  Matas 

in  extenso;  giving  priority  to  Halsted  in  nerve  blocking  and  other  discoveries  on 

local  anaesthesia  (see  pp.  150-152).) 

16.  Bartlett,  W.    An  estimate  of  the  value  of  local  anaesthesia  in  the  surgery  of 

today.   Tr.  South.  Surg.  &  Gynec.  Ass.,  Phila.,  1920,  xxxiii,  2-3. 

17.  Matas,  R.,  and  Kells,  C.  E.   The  discovery  of  conduction  anaesthesia  ....  ab- 

stracted from  the  correspondence  of  Drs.  Kells  and  Matas  and  from  the 
reports  of  Dr.  Matas  to  the  Louisiana  State  Medical  Society  and  the  Phila- 
delphia Medical  Journal,  November  3rd.,  1900,  entitled  "  Local  and  regional 
anaesthesia  with  cocaine,  etc." 

In:  A  booklet  entitled  "Dinner  to  Dr.  Halsted,  given  by  the  Maryland 
State  Dental  Association,  on  the  occasion  of  the  presentation  of  a  gold 
medal  by  the  National  Dental  Association,  at  the  Belvedere  Hotel,  Balti- 
more, April  1,  1922,  to  commemorate  his  pioneer  work  in  the  field  of  local 
surgical  anaesthesia."    Norman  T.  A.  Munder  &  Co.,  Baltimore,  1922. 


13 


LOCAL  ANAESTHESIA  WITH  WEAK  SOLUTIONS  OF  COCAINE  ' 

In  reference  to  the  cocaine  solution,  I  agree  with  Dr.  Matas  that  the 
principles  which  Schleich  has  emphasized,  and  which  I  emphasized  before 
him,  are  very  important  ones.  I  wish  to  say  a  word  in  reference  to  the  use 
of  weak  solutions.  For  many  years  we  used  solutions  that  had  little  cocaine 
in  them.  We  began  with  a  very  weak  solution  and  continued  with  water, 
while  in  some  cases  we  used  water  alone.  We  found  that  very  mild  solutions 
of  cocaine  were  better  than  water,  and  discovered  that  a  1 :  3000  or  1 :  5000 
worked  satisfactorily  in  every  case.  For  ordinary  purposes  this  is  sufficient, 
and  patients  do  better  when  very  little  cocaine  is  used.  Their  power  of 
resistance  is  greater,  and  later  they  lose  their  inhibition,  which  is  one  reason 
for  using  mild  solutions.  I  recall  the  case  of  an  old  gentleman  from  out 
of  town  who  was  suffering  from  two  hernias  where  cocaine  was  used  in  the 
operation.  A  1 :  1000  solution  was  employed  for  the  first  operation  and  he 
was  much  affected  by  the  cocaine,  although  very  little  was  used.  For  the 
first  twenty-four  hours  he  was  much  depressed,  and  said  that  he  would 
not  have  the  other  side  done.  We  finally  persuaded  him  to  let  us  do  it, 
which  we  did  with  a  very  mild  solution  indeed.  He  had  no  bad  effects  and 
stood  the  operation  much  better. 

My  first  publication  on  water  as  an  anaesthetic  is  of  course  remembered, 
and  in  the  two  articles  I  wrote  later  all  the  points  made  by  Schleich  are 
discussed. 

1  Brief  remarks  in  discussion  of  Dr.  Rudolph  Matas'  paper,  "  Traumatic  arterio- 
venous aneurisms  of  the  subclavian  vessels,  with  an  analytical  study  of  fifteen 
reported  cases,  including  one  operated  by  Dr.  Matas. 

American  Surgical  Association,  Baltimore,  May  7-9,  1901. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1901,  xix,  293-294. 


178 


SURGERY  OF  THE  INTESTINES 


A  CASE  OF  INTESTINAL  INCARCERATION  * 

Dr.  Wm.  S.  Halsted  presented  a  specimen  with  the  following  history : 

Anna  B.,  aet.  35,  Irish,  widow,  well  nourished,  and  mother  of  eight  chil- 
dren (youngest  five  years  old),  was  admitted  to  Charity  Hospital  (Black- 
well's  Island),  December  16,  1882,  complaining  of  constipation,  colicky 
pains,  distension  of  the  abdomen,  and  vomiting.  The  patient  stated  that, 
since  her  infancy,  she  had  been  subject  to  similar,  but  less  severe  attacks, 
and  remembered  five  previous  ones  distinctly — the  last  having  occurred  in 
March  of  this  year.  Heretofore  she  had  been  promptly  relieved  by 
"medicine,"  her  symptoms  having  persisted  on  only  one  occasion  for  as 
long  a  time  as  two  days,  and  their  subsidence  being  always  coincident  with 
the  escape  of  much  flatus.  Constipation  had  attracted  the  patient's  atten- 
tion for  several  days  prior  to  the  present  seizure,  which  developed  suddenly, 
about  one  week  before  admission,  while  drinking  a  cup  of  tea.  Since  then 
nothing  had  passed  from  her  bowels.  She  vomited  on  the  15th,  for  the  first 
time,  a  little  mucus,  and  had  continued  to  eject,  at  intervals  of  several  hours, 
frothy  mucus  and  possibly  bile,  but  at  no  time  stercoraceous  matter.  The 
house  physician  gave  a  cathartic  soon  after  admission.  My  attention  was 
called  to  the  case  on  the  following  day,  December  17th.  The  recorded  his- 
tory being  incomplete,  I  will  recite  it  as  accurately  as  possible  from  memory : 
I  found  the  patient  tossing  from  side  to  side,  moaning  loudly,  and  appar- 
ently in  great  distress.  The  countenance  was  slightly  flushed  but  not 
anxious.  The  respirations  were  27;  pulse  98;  temperature  98.5°.  The 
thighs  were  flexed.  The  abdomen  was  much  distended  and  unevenly  so, 
everywhere  tympanitic,  and  in  no  one  region  especially  sensitive  to  pressure. 

Diagnosis. — Intestinal  obstruction. 

I  ordered  morphine,  Irypodermically,  and  directed  that  enemata,  as  large 
as  possible,  should  be  administered  with  the  longest  available  tubes. 

December  18th. — The  patient,  confident  that  she  was  convalescing,  as- 
sured us  that  she  was  free  from  pain  and  had  passed  "  wind  "  per  anum. 
Respirations  were  22;  pulse  104;  temperature  98.5°.  I  could  not  ascertain 
positively  how  much  urine  had  been  voided,  but  the  nurse  estimated  four 
ounces  in  twelve  hours.  The  house  physician  stated  that  a  hard  oesophageal 
tube  was  introduced  (per  rectum)  last  evening  to  its  fullest  extent  (about 

Presented  at  the  New  York  Surgical  Society,  December  26,  1882.  (Stenographic 
report  has  been  reedited  by  the  editor.)  Although  this  article  appeared  previously 
to  "  Refusion  in  the  treatment  of  carbonic  oxide  poisoning  "  (which  is  Dr.  Halsted's 
first  published  contribution  to  surgery),  it  is  not  placed  chronologically  first  in  the 
volumes  because  it  was  not  prepared  by  Dr.  Halsted  and  is  only  a  stenographic  account 
of  Dr.  Halsted's  report  of  a  case  at  the  New  York  Surgical  Society.   (Editor.) 

N.  York  M.  J.,  1883,  xxxvii,  241. 

Also:  Med.  News,  Phila.,  1883,  xlii,  113-115. 

181 


182  INTESTINAL  INCARCERATION 

twenty  inches),  and  that  only  one  quart  of  fluid  could  be  injected,  which, 
when  evacuated,  brought  with  it  mucus,  but  no  gas  and  not  a  trace  of 
faeces.  I  repeated  the  injection  myself,  with  like  result,  and  noticed  that 
the  tube  was  in  several  places  most  singularly  bent  and  twisted. 

19th. — 5  p.  m.  Pulse  120,  and  intermittent.  At  6  p.  m.  the  patient  was 
anaesthetized.  Assisted  by  Dr.  "Weir,  I  proceeded  to  operate  under  the  car- 
bolic acid  spray  (1-40).  The  incision  in  the  median  line  extended  from  the 
umbilicus  to  the  pubes.  Upon  opening  the  peritonaeum  a  small  quantity  of 
serous  fluid  escaped  through  the  wound.  The  large  intestine,  very  much 
distended  and  presenting  a  few  small  superficial  ecchymoses,  occupied  the 
entire  field  of  view,  being  folded  upon  itself  longitudinally.  The  separation 
of  the  folds  exposed  the  quite  normal  small  intestine.  After  a  somewhat  pro- 
longed and  unsatisfactory  search  for  the  cause  of  the  obstruction,  which  was 
evidently  below  the  flexura  lienalis,  there  could  be  felt  with  the  right  hand 
a  dense  cylindrical  band,  about  the  size  of  one's  little  finger,  very  deeply 
situated,  and  stretching  from  near  the  promontory  of  the  sacrum,  obliquely 
upward  and  outward,  to  the  parietes  of  the  left  hypochondrium,  not  far 
from  the  tip  of  the  twelfth  rib.  The  abdominal  incision  was  then  extended 
to  within  about  two  inches  of  the  xiphoid  cartilage.  The  obstructing  cord 
being  exposed,  it  could  be  seen  to  have  its  apparent  origin  from  the  trans- 
verse colon,  and  was  divided  between  two  stout  catgut  ligatures,  which  were 
passed  around  it  by  means  of  an  aneurism  needle.  Below  the  band,  and 
clearly  compressed  by  it,  were  two  tubes  of  large  intestine,  one  of  which 
filled  with  air  as  soon  as  released,  while  the  other  did  not.  The  patient's 
condition  was  too  bad  to  justify  much  further  investigation,  although  it 
was  evident  that  the  disposition  of  the  sigmoid  flexure  was  most  puzzling, 
and  possibly  offered  another  obstacle  to  the  escape  of  intestinal  contents. 
The  distended  colon,  which  had  been  protected  throughout  the  operation  by 
towels  warmed  in  a  solution  of  carbolic  acid  (1-40),  was  replaced  without 
very  much  difficulty,  and  the  wound  united  by  a  double  row  of  sutures ;  the 
deep  of  silver,  including  the  peritonaeum. 

20th. — 7  p.  m.  The  patient  died.  Ever  since  the  operation  the  patient 
was  observed  by  the  internes  and  nurses  to  have  passed  large  quantities  of 
gas  from  the  bowels. 

21st. — 12  m.  Autopsy. — There  was  quite  firm  union  all  along  the  line  of 
the  incision.  The  transverse  colon  was  slightly  adherent  to  the  wound  a 
little  below  the  umbilicus.  The  large  intestine  reached  to  the  fourth  inter- 
costal space  on  the  left  side.  Attached  to  the  anterior  surface  of  the  trans- 
verse colon  at  about  its  middle,  and  having  its  origin  in  the  great  omentum, 
was  one  portion  of  the  divided  band  with  its  catgut  ligature;  the  other  part 
being  intimately  blended,  and  apparently  continuous  with  the  diaphrag- 
matic peritonaeum  between  the  eleventh  and  twelfth  ribs.  The  specimens 
before  you  show  the  attachments  of  the  band. 

Figs.  14  and  15,  drawn  in  the  light  of  the  autopsy,  are  intended  to  illus- 
trate what  presumably  existed  before,  and  immediately  after,  the  operation. 
The  xxx  designate  the  sigmoid  flexure  looped  and  twisted  upon  itself  from 
right  to  left.  The  sigmoideo-rectal  junction  was  sufficiently  narrowed  in  the 
bite  of  the  volvulus  to  prevent  the  ready  escape  of  flatus  per  rectum.   This 


INTESTINAL  INCARCERATION 


183 


constriction  was  evidently  of  very  long  standing,  and  intensified  somewhat 
by  the  underlying  falciform  fold  of  its  mesocolon  which  normally  extends 
from  the  mesentery  to  the  upper  end  of  the  rectum,  and  which,  in  this  case, 
was  unusually  strong  and  prominent,  with  its  concavity  directed  ventrally. 

The  pathogenesis  may  then  have  been:  First,  a  noninflammatory  ad- 
hesion in  intra-  or  early  extrauterine  life  of  a  considerable  portion  of  large 
omentum  (mesogastrium)  to  the  parietal  peritonaeum — adhesions  of  this 
nature  being  incidental  to  development,  as  urged  by  Langer  and  verified 
by  Toldt;  second,  an  embarrassed  growth  of  the  sigmoid  flexure,  giving 


ir  rib 


BAND 


RECTUM 
Fig.  14. — Before  Operation. 


BAND   OIVIDEO 


Fig.  15.— Immediately  After  Operation. 


rise  to  a  rotation  of  the  same,  which  was  permitted  by  the  great  length 
of  the  free  mesocolon  at  that  early  period,  or  by  its  coincident  development ; 
third,  a  narrowed  sigmoideo-rectal  junction,  its  growth  having  been  some- 
what restrained  and  its  lumen  reduced  by  pressure  from  without;  fourth, 
acute  symptoms  due,  as  suggested  by  Busch,  to  sudden  distension  of  the  gut 
above  and  the  retraction  of  mucous  membrane  from  below  the  omental  band, 
possibly  preceded  by  further  intrusion  of  descending  colon  under  the  site 
of  the  constriction.  I  would  suggest,  in  similar  cases,  the  advisability  of 
operating  early,  not  only  that  the  patient  may  survive  the  shock,  but  to 
anticipate  a  degree  of  hyperdistension  of  the  intestine  from  which  it  can 


184  INTESTINAL  INCARCERATION 

never  recover.  If  there  is  reason  to  suspect  the  existence  of  a  further  source 
of  obstruction,  or  if  the  tension  within  the  distended  gut  cannot  be  decidedly 
relieved  by  simpler  measures,  I  believe  that  laparocolostomy  or  enterostomy, 
as  the  condition  may  dictate,  to  be  indicated. 

Following  the  discussion  of  this  case  by  Drs.  Sands,  Weir,  and  Gerster, 
Dr.  Halsted  remarked  that  he  also  introduced  a  fine  hypodermic  needle  into 
the  distended  intestines  in  his  case,  and  observed  precisely  the  same  thing 
which  Dr.  Gerster  had  mentioned,  namely,  the  exit  of  a  small  drop  of  intes- 
tinal fluid  upon  the  withdrawal  of  the  needle.  Only  a  small  amount  of  gas 
escaped,  and  that  very  slowly.  Furthermore,  Dr.  Weir  retained  the  intestines 
in  position  to  a  considerable  extent  by  means  of  towels  which  had  been 
dipped  in  warm,  carbolized  water,  and  after  some  manipulation  they  were 
returned  to  the  abdominal  cavity. 


CIRCULAR  SUTURE  OF  THE  INTESTINE1 

AN  EXPERIMENTAL  STUDY 

Among  the  most  brilliant  triumphs  of  modern  surgery  are  those  which 
have  attended  operations  involving  laparotomy.  We  can  offer  a  scientific 
explanation  why  many  abdominal  operations — above  all,  ovariotomy — should 
succeed  so  well  even  without  the  use  of  antiseptics.  The  chief  danger  of 
these  operations  is  the  development  of  peritonitis  of  a  septic  or  purulent 
nature.  Contrary  to  former  beliefs  Wegner 2  demonstrated  experimentally 
that  the  mere  exposure  of  the  peritonaeum  to  the  air  does  not  cause  peri- 
tonitis. The  recent  experiments  of  Grawitz 3  have  shown  that  the  access  of 
the  microorganisms  of  suppuration  to  the  peritonaeal  cavity  does  not  alone 
suffice  to  induce  peritonitis.  The  absorbing  power  of  the  peritonaeal  surfaces 
is  very  great  and,  under  favorable  circumstances,  pyogenic  substances  are 
quickly  absorbed  from  the  peritonaeal  cavity  without  causing  suppurative 
inflammation.  In  confirmation  of  the  experiments  of  Grawitz  I  have  inserted 
pure  cultures  of  the  pus  organisms,  as  well  as  small  pieces  of  suppurating 
tissue  and  particles  of  faeces,  into  the  peritonaeal  cavities  of  dogs  without 
producing  peritonitis. 

Accessory  causes  must  be  present  in  order  that  pyogenic  substances  may 
induce  purulent  peritonitis.  These  accessory  conditions,  various  as  they  may 
be,  have  in  common  the  attribute  that  they  prevent  absorption  or  removal 
from  the  peritonaeal  cavity  of  pyogenic  substances,  more  particularly  of  the 
bacteria  of  suppuration. 

Without  entering  into  a  detailed  consideration  of  these  conditions,  the 
following  may  be  mentioned  as  of  especial  importance  in  surgical  operations 
involving  the  peritonaeum :  the  presence  in  the  peritonaeal  cavity  of  blood 
or  other  stagnating  fluids,  the  existence  of  necrotic,  wounded,  or  diseased 
tissue  in  connection  with  the  peritonaeal  cavity,  and  the  presence  of  some 
focus  from  which  pyogenic  bacteria  may  enter  the  peritonaeal  cavity  in 
larger  number  or  more  rapidly  than  they  can  be  absorbed.    It  is  evident 

1  My  experiments  were  completed  April  1,  1887,  and  in  a  lecture  which  I  delivered 
at  the  Harvard  Medical  School,  April  5,  1887,  I  gave  in  substance  what  I  have 
written  for  this  article. 

Am.  J.  M.  Sc,  Phila.,  1887,  n.s.,  xciv,  436-461.    (Reprinted.) 

2  Wegner.   Arch.  f.  klin.  Chirurgie,  Bd.  xx. 

3  Grawitz :    Charite-Annalen,  Jahrg.  xi. 

185 


186  CIRCULAR  SUTURE  OF  THE  INTESTINE 

that  bacteria,  which  otherwise  would  be  readily  absorbed,  may  take  lodge- 
ment and  grow,  if  they  find  in  the  peritonaeum  stagnating  nutritive  fluids 
or  ulcerated  and  necrotic  tissue.  For  manifest  reasons  dead  spaces,  which 
play  such  an  important  role  in  suppurative  inflammations  elsewhere,  are  less 
likely  to  be  formed  in  the  peritonaeal  cavity  than  in  most  other  situations. 

The  experimental  results  which  have  been  mentioned  and  the  deductions 
from  them  enable  us  to  explain  the  brilliant  success  of  skilful  ovariotomists, 
even  when,  like  Lawson  Tait,  they  ostentatiously  discard  the  use  of 
antiseptics. 

In  striking  contrast  to  the  results  of  ovariotomy  are  those  of  intestinal 
suture.  Not  but  that  here,  too,  brilliant  successes  have  been  recorded,  but 
the  death-rate  attending  enterorrhaphy  has  been  large,  and,  in  general, 
the  operation,  even  in  the  hands  of  the  most  skilful  surgeons,  has  been  capri- 
cious in  its  results.  While  admitting  that  an  operation  so  delicate  and  so 
difficult  in  its  technique  as  enterorrhaphy  should  be  judged  not  by  statistics 
collected  at  random  from  all  possible  sources,  but  by  the  results  of  individual 
operators  of  approved  knowledge  and  skill,  it  yet  remains  true  that  even 
from  this  point  of  view  the  results  are  not  satisfactory,  although  they  are 
such  as  to  encourage  further  efforts  in  perfecting  the  operation. 

In  the  hope  that  an  experimental  investigation  of  the  subject  of  intestinal 
suture  might  contribute  somewhat  to  our  knowledge  of  the  causes  of  fail- 
ure as  well  as  of  the  conditions  of  success  of  enterorrhaphy,  I  have  under- 
taken during  the  past  winter  a  series  of  experiments  in  the  Pathological 
Laboratory  of  The  Johns  Hopkins  University,  in  Baltimore.  I  wish  on  this 
occasion  to  express  my  thanks  to  Prof.  Wm.  H.  Welch,  the  Director  of  the 
Laboratory,  for  his  kindness  and  advice,  and  also  to  acknowledge  my  in- 
debtedness to  Dr.  F.  P.  Mall,  Fellow  in  Pathology  of  The  Johns  Hopkins 
University,  for  his  kind  assistance  in  the  operations,  and  especially  for  call- 
ing my  attention  to  many  points  concerning  the  minute  anatomy  of  the 
intestine.  Dr.  Mall's  suggestions  were  of  great  value  to  me. 

The  experiments  were  performed  upon  dogs,  anaesthetized  usually  with 
morphine  and  ether;  they  include  sixty-nine  circular  resections  and  circular 
sutures  of  the  small  intestine. 

The  history  of  the  operation  of  intestinal  suture  has  been  described  so 
often  and  so  well  that  it  is  not  necessary  in  an  experimental  study  of  the 
subject  to  go  over  this  historical  ground  again. 

Before  describing  my  experiments,  I  wish  to  call  attention  to  certain 
points  relating  to  the  anatomy  of  the  intestinal  wall,  a  knowledge  of  which 
is  of  the  utmost  importance  to  the  surgeon  who  performs  intestinal  suture. 
In  looking  through  the  literature  of  intestinal  suture  I  cannot  find  that  any 
one  has  called  sufficient  attention,  from  a  surgical  point  of  view,  to  the 


CIKCULAK  SUTURE  OF  THE  INTESTINE  187 

structure  of  the  different  coats  of  the  intestine,  particularly  to  their  physical 
properties.  Indeed,  the  descriptions  in  surgical  textbooks,  as  well  as  in 
monographs  and  articles  treating  especially  of  intestinal  suture,  and  the 
drawings  which  are  frequently  inserted  to  elucidate  the  subject,  lead  me  to 
believe  that  the  current  ideas  among  surgeons  are  not  only  incomplete,  but 
absolutely  incorrect  as  regards  some  important  details  in  the  structure  of 
the  intestinal  coats.  If  these  errors  related  to  matters  of  only  histological 
interest  their  practical  bearing  would  be  very  slight,  but  my  experiments 
have  led  me  to  attach  great  weight,  in  the  successful  performance  of  enteror- 
rhaphy,  to  an  accurate  knowledge  of  the  thickness  and  physical  characters 
of  the  submucous  coat  of  the  intestine,  and  I  am  not  aware  that  the  impor- 
tance of  this  coat  in  connection  with  this  operation  has  hitherto  been 
emphasized. 

The  old  views  of  Jobert  and  Lembert  as  to  the  structure  of  the  intestinal 
wall  seem  to  have  been  adopted  by  modern  surgeons  with  little  or  no  modi- 
fication. The  peritonaeal  coat,  for  instance,  is  believed  to  be  thick  enough 
and  sufficiently  strong  to  hold  a  stitch,  and  the  existence  of  the  submucosa, 
for  us  the  most  important  coat,  has  been  generally  ignored. 

A  few  quotations  from  recent  writers  will  substantiate  these  statements. 
Thus  Madelung/  in  his  admirable  contribution  to  intestinal  suture,  writes, 
"  The  needle  now  penetrates  in  the  usual  manner  the  two  ends  of  the  intes- 
tine, passing  between  serosa  and  muscularis."  Reichel B  insists  upon  the 
accurate  "adaptation  of  the  two  edges  of  the  wound,  particularly  of  the 
serous  coats,"  and,  having  described  the  manner  of  taking  the  first  row  of 
stitches,  continues,  "over  this  comes  then  the  external  suture  which  in- 
cludes only  the  serosa."  Maydl,8  Kocher/  and  many  others  could  be  quoted 
in  the  same  sense  to  show  the  prevalence  of  the  idea  that  intestinal  surfaces 
may  be  sutured  by  stitches  including  only  the  serous  membrane. 

I  fail,  moreover,  to  find  in  the  writings  of  Gussenbauer,  von  Winiwarter, 
Kocher,  Czerny,  Rydygier,  Madelung,  Reichel,  Maydl,  and  others  the  proper 
importance  attached  to  the  inclusion  of  a  portion  of  the  submucosa  in  sutur- 
ing the  intestine.  The  following  quotations  will  suffice  to  show  how  little 
importance,  from  a  surgical  point  of  view,  has  been  attached  to  the 
submucosa. 

Reichel 8  completely  ignores  the  existence  of  the  submucosa  when  he  says, 
"  It  is  to  be  recommended  in  making  the  internal  row  of  sutures,  after 

4 Madelung:  Arch.  f.  klin.  Chirurgie,  Bd.  xxvii.  p.  321. 

5  Reichel:  Deutsche  Zeitschrift  f.  Chirurgie,  Bd.  xix.  pp.  268  and  270. 

'Maydl:   Allg.  Wien.  med.  Zeitung,  October,  1885,  p.  475. 

7  Kocher:  Centralblatt  f.  Chirurgie,  1880,  No.  29,  p.  466. 

"Reichel:  hoc.  cit.,  pp.  269  and  270. 


188 


CIRCULAR  SUTURE  OF  THE  INTESTINE 


carefully  turning  in  the  mucous  membrane,  to  stick  the  needle  close  in  front 
of  the  edge  of  the  wound  through  the  serosa  and  muscularis,  and  to  draw 
it  out  at  the  edge  of  the  wound  between  the  muscularis  and  mucosa,  and  on 
the  other  border  to  proceed  in  reverse  order." 

Maydl,9  too,  recognizes  but  three  coats,  for  he  writes,  "  Then  the  two 
external,  possibly  retracted,  intestinal  coats  are  to  be  drawn  together  by 
means  of  several  stitches  which  grasp  the  entire  thickness  of  the  intestinal 
wall  with  the  exception  of  the  already  coaptated  mucous  coats,  whereby 
serous  surfaces  when  present  are  brought  into  broad  apposition."  Had 
Kocher  appreciated  the  resistance  furnished  to  the  needle  on  entering  the 
submucosa,  he  might  have  explained  how  perforation  into  the  lumen  of  the 
gut  is  to  be  avoided,  and  not  merely  have  said,  "  The  wall  of  the  intestine  is 


Fig.  16. 

p.  Peritonaeum.  I.  Longitudinal  Muscular  Coat.   c.  Circular  Muscular  Coat.   s.  Sub- 
mucosa. mm.  Muscularis  Mucosae.  L.  Glands  of  Lieberkuhn. 


not  to  be  punctured  in  its  entire  thickness," 10  and  "  we  passed  the  stitches 
according  to  Lembert  through  the  thickness  of  the  intestinal  wall,  avoiding, 
if  possible,  penetrating  the  lumen."  u  Czerny,  who  has  for  a  long  time  de- 
voted himself  earnestly  and  most  usefully  to  the  subject  of  intestinal  suture, 
does  not  refer  to  the  submucosa  in  describing  the  technique  of  the  operation." 
Fig.  16,  kindly  drawn  for  me  by  Dr.  Mall,  is  a  diagram  of  the  wall  of  the 
dog's  intestine,  and  is  intended  to  represent  accurately  the  relative  thick- 
ness of  the  several  coats.  The  serosa  is  prolonged  beyond  the  outer  mus- 
cular coat  to  emphasize  its  thinness.    Between  the  submucosa  and  glands 

8  Maydl:   hoc.  cit.,  p.  489. 

"Kocher:    Correspondenzblatt  f.  Schweizer  Aertze,  1878,  p.  155. 

11  Kocher:   Centralblatt  f.  Chirurgie,  July,  1880,  p.  468. 

"Czerny:   Berlin,  klin.  Wochenschrift,  November,  1880,  p.  641  et  sea. 


CIECULAE  SUTURE  OF  THE  INTESTINE  189 

of  Lieberkiihn — in  other  words,  between  it  and  the  lumen  of  the  intestine — 
practically  nothing  intervenes ;  and,  literally,  nothing  but  the  two  layers  of 
muscularis  mucosae  and  fibrosa  mucosae  respectively.  Fully  two-thirds  of 
the  thickness  of  the  wall  of  the  intestine  is  mucous  membrane.  When  the 
needle,  therefore,  has  been  passed  through  its  outer  third  it  must  have 
entered  the  glands  of  Lieberkiihn  and,  hence,  the  lumen  of  the  gut.  It  is  an 
easy  matter  to  isolate  the  submucosa.  The  outer  muscular  coats  strip  from 
it  readily,  and  the  mucous  membrane  can  be  rapidly  scraped  off  with  a  knife. 
Thus  obtained,  the  submucosa  is  found  to  be  an  exceedingly  tough,  fibrous 
membrane.  It  is  air-tight  and  water-tight,  and  is  the  "  skin  "  in  which 
sausage  meat  is  stuffed.  It  is,  moreover,  the  coat  of  the  intestine  from  which 
"  catgut "  is  made. 

A  needle,  on  being  pushed  vertically  through  the  wall  of  the  intestine, 
meets  with  considerable  resistance  when  it  reaches  the  submucosa ;  and  still 
greater  resistance  is  encountered  if  it  be  attempted  to  pass  the  needle  hori- 
zontally through  its  meshes.  A  delicate  thread  of  this  tissue  is  very  much 
stronger  and  better  able  to  hold  a  stitch  than  is  a  coarse  shred  of  the  entire 
thickness  of  the  muscular  ami  serous  coats.  Upon  the  discovery  of  the  latter 
fact,  at  which  I  was,  perhaps,  as  much  surprised  as  most  surgeons  will  be 
at  the  statement  of  it,  it  naturally  occurred  to  me  that  it  would,  if  feasible, 
be  well  to  include  a  portion  of  the  submucosa  in  the  suture.  Before  attempt- 
ing this,  however,  I  wished  to  test  the  merits  of  a  suture  which  included 
nothing  but  the  serosa  and  muscularis,  and  I,  therefore,  performed  the  fol- 
lowing experiment: 

Experiment  A. — Small  young  dog.  Operated  on  January  18,  1887. 
Irrigation  with  solution  of  corrosive  sublimate,  1 :  1000.  Needles  with  dulled 
ends  employed  for  sewing.  Circular  resection  of  intestine.  Two  rows  of 
interrupted  stitches  passed  as  deep  as,  but  not  including  any  portion  of,  sub- 
mucosa— suture  of  muscular  coat.  The  stitches  tore  out  badly  (particularly 
those  of  the  first  row)  and  had  to  be  frequently  retaken. 

January  23d. — Dog  found  dead.  Autopsy:  Suppurative  peritonitis; 
sutures  had  given  way  completely. 

Blunt  needles  were  used  in  the  foregoing  experiment  to  enable  me  to 
penetrate  down  to,  and  no  deeper  than,  the  submucous  coat.  Dr.  Mall  had 
previously  called  my  attention  to  the  fact  that,  with  the  eye-end  of  a  needle, 
one  would  not  unwittingly  puncture  the  submucosa ;  for  the  force  required 
to  enter  it  at  all  with  the  rounded  end  of  a  needle  is  sufficient  to  perforate  it, 
and,  that  too,  not  without  a  positively  unmistakable  and  characteristic  jerk. 
I  soon  discovered  that,  even  to  the  sharpened  end  of  a  needle,  sufficient  re- 
sistance is  offered  by  the  submucosa  to  be  easily  appreciable,  and  that  it  is 
possible  and,  with  very  little  practice,  not  difficult  to  pick  up  at  each  stitch 


190  CLBCULAB  SUTTEE  OF  THE  INTESTINE 

a  thread-like  piece  of  submucosa  without  mcurring  the  danger  of  passing 
into  the  lumen  of  the  gut. 

Persuaded  by  Experiment  A.  and  others  of  a  similar  nature,  that  the 
musculo-peritonaeal  suture  is  not  to  be  trusted,  I  performed  Experiments 
B  and  C  in  order  to  test  the  advisability  of  taking  up,  with  each  stitch,  a 
thread  of  the  submucosa. 

Experiment  B. — Medium-sized  dog.    Operation  Januar  '.    To 

include  in  each  stitch  a  thread  of  submucosa.  Irrigation  with  solution  of 
corrosive  sublimate,  1 :  10,000.  Glass  clamps :  suture,  catgut.  Two  rows  of 
interrupted  stitches. 

January  25th. — Dog  has  been  doing  very  well  ever  since  the  operation. 

February  19th. — Apparently  perfectly  well.  Killed.  Autopsy:  Circular 
intestinal  wound  perfectly  healed :  no  adhesions,  except  slight  ones  over  the 
line  of  suture  anteriorly. 

I  wish  to  call  attention  here  to  a  point  to  be  emphasized  more  prominently 
later,  viz.,  that  whereas  in  Experiments  1  and  2  of  Group  I,  the  adhesions 
were,  as  we  shall  see,  extensive  enough  to  have  eventually  caused  death  in 
one  case,  and  to  have  threatened  it  in  the  other,  in  Experiment  B  they  were 
strikingly  trivial. 

Experiment  C. — Operation  January  20.  1887.  To  reverse  about  one 
foot  of  intestine.  (This  operation  was  done  for  a  purpose  not  belonging  to 
the  subject  of  this  article.)  Steps  of  operation:  1.  Complete  section  of 
intestine  in  two  places,  about  one  foot  apart.  2.  Afferent  (proximal)  ends 
stitched  together.  3.  Efferent  (distal)  ends  brought  together  over  the  line 
of  suture  of  afferent  ends,  and  sutured.  Straight  needles.  Two  rows  of 
interrupted  silk  stitches.  With  each  stitch  a  thread  of  submucosa  was  taken 
up.   Irrigation  with  solution  of  corrosive  sublimate,  1: 10,000. 

Dog  died  of  shock  a  few  hours  after  operation.  Autopsy,  by  Dr.  Mall : 
Careful  examination  of  suture  made,  to  ascertain  if  any  of  the  stitches  had 
penetrated  into  the  lumen  of  the  gut:  not  one  was  found  to  have  done  so. 
No  peritonitis. 

This  experiment  was  a  satisfactory  one  to  me,  in  that  it  demonstrated  the 
feasibility  of  carrying  the  stitches  into  the  submucosa. 
To  satisfy  my  curiosity,  I  made  experiments  D,  E,  and  F. 

Experiment  D. — Small,  brindled  and  white  bulldog  (pup).  Operation 
January  29,  1887.  To  suture  the  submucosa  alone.  1.  Split  muscularis  for 
about  two  centimetres  from  cut  edges  along  mesenteric  and  free  borders  of 
intestine.  2.  Stripped  back  the  muscular  flaps  thus  marked  out  and  ex- 
posed two  centimetres  of  submucosa.  3.  Applied  two  rows  of  interrupted 
stitches  to  the  exposed  submucosa,  appropriating  but  a  thread  of  it  to  each 
stitch.  4.  Sewed  the  musculo-peritonaeal  flaps  together  over  the  line  of 
the  circular  suture. 

January  31st. — Dog  found  dead.  Autopsy:  Complete  slough  of  flaps, 
and  gaping  of  circular  wound. 


CIECULAR  SUTURE  OF  THE  INTESTINE  191 

Expeeiment  E. — Large,  long-haired,  white  dog.  Operation  January  21st. 
Circular  suture  of  submucosa  alone.  1.  Circular  division  of  musculo- 
peritonaeal  coat,  and  stripping  off  of  cuffs  to  expose  about  one  centimetre  of 
submucosa.  2.  Buried-knot  quilt  (vide  Fig.  17)  stitches  applied  before  com- 
pleting the  section  of  the  gut.  3.  Section  of  gut  completed,  and  buried-knot 
quilt  stitches  tied.  4.  Two  rows  of  continuous  submucosa  suture.  5.  Cut 
edges  of  musculo-peritonaeal  cuffs  turned  out,  and  the  under  surface  of  the 
cuffs  coaptated,  and  held  by  a  few  stitches. 

February  1st. — Dog  is  dead.  Autopsy:  Submucous  stitches  still  hold;  but 
gangrene,  starting  from  the  musculo-peritonaeal  cuffs,  extends  for  about  one 
foot  above  the  circular  suture. 

Expeeiment  F. — Operation  same  as  in  Experiment  E.  Dog  died  of  ether. 

We  are  now  prepared  to  consider  my  first  series  of  operations.  In  order 
to  classify  conveniently  the  modes  of  suture,  the  experiments  will  not  be 
numbered  precisely  in  the  order  in  which  they  were  performed. 

Geoup  I.  Lembeet's  Stitches 

Expeeiment  1. — Small,  young,  black  bitch.  Operation  January  6,  1887. 
Resection  of  about  two  and  a  half  inches  of  small  intestine.  Glass-slide 
clamps.  Irrigation  with  solution  of  corrosive  sublimate,  1 :  40,000.  Suture, 
fine  sublimate  silk.  Two  rows  of  interrupted  stitches. 

January  7th. — Dog  walks  about.  Is  not  much  depressed.  Vomits  occasion- 
ally. Has  been  seen  to  pass,  per  rectum,  a  few  drops  of  blood-stained  mucus. 

8th. — Dog  is  playful.  No  evidence  of  peritonitis.  Takes  milk. 

11th. — Apparently  perfectly  well. 

February  7th. — Dog  emaciated  almost  to  a  skeleton.  Has  refused  food  for 
about  one  week.  Is  evidently  dying  of  starvation.  Killed.  Autopsy:  Line 
of  suture  adherent  to  adjacent  intestines.  Several  acute  bends  in  intestine, 
two  or  three  inches  apart,  caused  by  adhesions.  Intestine  nowhere  dilated. 
Mucous  membrane  at  the  line  of  suture  quite  flat. 

Riedel 1S  relates  a  similar  case,  the  death  of  a  dog  from  inanition,  due  to 
finger-like  bending  of  the  intestine,  without  dilatation  or  other  evidences 
of  obstruction. 

Expeeiment  2. — Medium-sized,  gray  dog.  Operation  January  19th.  No 
antiseptics.  Irrigation  with  warm  physiological  salt  solution.  No  clamps. 
Suture,  two  rows  of  Lembert's  stitches.  Fear  that  too  much  tissue  has  been 
turned  in. 

January  25th. — Dog  has  not  been  very  lively  since  the  operation,  but 
takes  milk  naturally. 

27th. — Dog  appears  better. 

February  1st. — Seems  perfectly  well. 

2d.— Killed.  Autopsy:  Omentum  adherent  over  line  of  suture:  numer- 
ous other  adhesions.  Intestine,  above  suture,  dilated  to  about  four  times 
its  natural  size.   Suture  perfectly  firm. 

"Riedel:   Deutsche  Gesellschaft  fur  Chirurgie,  1883,  p.  25. 


192  CIRCULAR  SUTURE  OF  THE  INTESTINE 

Expeeiments  3,  4,  5. — Operations  December  12,  13,  and  14,  1886.  To 
isolate  loops  of  intestine.  Double  circular  resection,  and  double  suture. 
Suture,  horse-hair. 

All  three  cases  died  within  two  or  three  days  of  the  operation,  from 
purulent  peritonitis. 

Experiment  6. — Young,  small,  brindled  dog.  Operation  January  9, 
1887.  To  isolate  loop  of  intestine.  1.  Intestine  divided  in  two  places,  about 
one  foot  apart.  2.  Ends  of  gut  thus  isolated,  sewed  together.  3.  The  remain- 
ing ends  stitched  together  to  establish  the  intestinal  continuity.  Irrigation 
with  solution  of  corrosive  sublimate,  1 :  4000.  Glass  clamps.  Suture,  fine 
sublimate  silk.  Czerny's  "  Etagennaht."  Operation  lasted  two  hours.  As 
the  abdominal  wall  was  being  sewed,  fresh  ether  was  administered,  and  the 
dog  died  of  respiratory  paralysis.  The  heart  continued  to  beat  for  more  than 
fifteen  minutes  after  the  respiration  had  ceased.  No  attempt  was  made  to 
revive  the  animal  by  artificial  respiration. 

ExrEKiMENT  7. — Small,  brindled  bitch.  Operation  January  10,  1887. 
To  isolate  loop.  Steps  of  operation  the  same  as  in  Experiment  6.  Czerny's 
suture.  Twenty  minutes  required  for  the  loop  suture,  and  fifteen  minutes 
for  the  continuity  suture.  One  hour  and  fifteen  minutes  for  the  entire  opera- 
tion. Dog  ceased  breathing  as  abdomen  was  being  sewed.  Heart  continued 
to  beat.  Artificial  respiration  employed  for  thirty  minutes  before  active 
respiration  became  reestablished. 

January  11th. — Dog  still  alive,  and  able  to  walk.  No  vomiting.  Natural 
stool. 

12th. — Found  dead.  Autopsy:  Local  peritonitis  referable  to  sutures. 
Each  stitch  occupies  a  focus  of  pus.  Conclude  that  the  silk  used  may  not 
have  been  sufficiently  disinfected,  for  it  was  not  placed  in  the  sublimate 
solution  until  just  before  the  operation  was  undertaken. 

Experiment  8. — Rather  large,  black  and  white  dog.  Operation  Janu- 
ary 8,  1887.  To  isolate  loop  of  intestine.  Irrigation  with  solution  of  cor- 
rosive sublimate,  1 :  10,000.  Glass  clamps.  Suture,  catgut ;  Hagedorn's 
needles.  Three  rows  of  Lembert's  stitches.  Many  of  the  stitches  tore  out, 
and  had  to  be  reapplied.  Some,  certainly,  perforated  into  lumen  of  gut. 
Expressed  myself  at  the  time  as  being  dissatisfied  with  the  operation.  Felt 
sure  that  the  dog  would  die,  because  I  thought  that  I  had  been  unusually 
clumsy  in  my  technique. 

January  9lh. — Dog  lively,  and  seems  well. 

25th. — Dog  has  not  had  a  bad  symptom  since  the  operation. 

February  1st. — Not  so  well. 

3d. — Refuses  both  meat  and  drink. 

9th. — Dog  is  evidently  starving  to  death.  Reopen  abdomen,  find  many 
and  very  strong  adhesions.  Both  circular  sutures  firm.  The  isolated  loop  is 
distended  to  about  the  size  of  an  inflated  human  transverse  colon,  with 
faecal-smelling,  thick,  brownish-gray  fluid ;  and  its  wall  is  two  or  three  times 
as  thick  as  normal. 


CIRCULAR  SUTURE  OF  THE  INTESTINE  193 

That  these  cases  (Group  I)  testify  to  the  defectiveness  of  my  technique, 
I  am  eager  to  admit;  at  the  same  time  I  find  no  proof  that  the  method 
of  any  one  else  has  been  otherwise  than  very  uncertain.  The  single-resection 
experiments  (Group  I),  although  they  might  be  called  successful,  must, 
when  contrasted  with  Experiment  A,  and  with  those  which  are  to  follow 
(Group  II),  be  regarded  with  dissatisfaction.  The  serious  adhesions  which 
were  present  in  the  former  cases,  indicate  an  imperfect  method ;  and  in  the 
absence  of  any  such  in  the  latter  lies  the  promise  of  a  better  technique.  The 
most  favorable  accounts  of  single  resections  on  dogs  come  from  Madelung 
and  Rydygier.  The  one  reports  nine,  and  the  other  ten  experiments  as 
successful. 

Studying  Rydygier's  cases,"  I  observe  that,  whenever  an  autopsy  was 
made,  extensive  adhesions  were  found,  as  is  evident  by  the  following 
quotations : 

"  Experiment  1 The  site  of  resection  is  bound  by  adhesions  to 

the  contiguous  loops  of  intestine." 

*  Experiment  2 The  intestinal  loops  which  lie  near  to  the  site  of 

resection,  are  bound  together  by  adhesions." 

"  Experiment  3 The  site  of  resection,  which  is  completely  healed, 

is  bound  by  adhesions  to  the  abdominal  wound;  furthermore,  several  loops 
of  intestine  are  glued  together. 

"  Experiment  4 The  abdominal  wound  is  healed,  and  the  omen- 
tum is  adherent  to  it.  Several  loops  of  intestine  are  matted  together  about 
the  site  of  the  resection,  and  in  separating  them  the  intestinal  suture  gives 
way  to  a  slight  extent." 

Furthermore,  of  the  six  unautopsied  animals,  not  one,  perhaps,  had  lived 
long  enough,  at  the  time  of  Rydygier's  writing,  to  justify  the  belief  that 
death  from  adhesions  might  not  ultimately  have  ensued. 

Rydygier's  tenth  experiment  was  made  September  7th,  and  on  the  10th 
of  October  of  the  same  year  his  article  appeared. 

We  cannot  analyze  Madelung's  work  on  dogs,  because  he  has  not  thought 
it  worth  while  to  detail  his  experiments.  In  recommendation  of  his  "  Knor- 
pelplattennaht,"  he  says : 15 

"  I  wish  to  say  in  its  favor,  that  in  the  nine  experiments  on  animals  in 
which  I  performed  in  this  manner  circular  intestinal  and  gastric  resection, 
an  immediate  and  complete  union  took  place  in  every  instance.  In  no  in- 
stance did  escape  of  faeces  take  place.  I  do  not  think  it  worth  while  to  give 
a  detailed  account  of  these  experiments,  which  were  instructive  enough 
to  me." 

"Rydygier:    Berlin,  klin.  Wochenschr.,  1881,  p.  593. 
15  Madelung,  I.  c,  p.  323. 
14 


194  CIRCULAR  SUTURE  OF  THE  INTESTINE 

I  have  no  doubt  that  the  results  of  the  gentlemen  just  quoted  were  much 
better  than  I  could  have  obtained  by  their  methods  as  they  describe  them ; 
for  each,  with  his  great  experience,  must  have  acquired  an  art  of  sewing 
which,  from  a  scientific  standpoint,  is  not  sufficiently  precise  to  be  com- 
municated to  others. 

To  read  Kaiser's  "  experiments  is  to  become  convinced  of  the  uncertainty 
with  which,  in  the  taking  of  stitches,  he  must  contend  who  does  not  avail 
himself  of  the  guidance  offered  by  the  submucosa. 

"  Experiment  1 Autopsy  reveals  a  silk  thread  projecting  into 

the  lumen  of  the  intestine,  about  which  there  is  a  small  lens-like  depression." 

"  Experiment  3 On  the  stomach,  on  its  inner  side,  one  recog- 
nizes the  cicatrix  in  the  slightly  elevated  ridge.  On  the  duodenum,  very 
close  to  the  cicatrix,  are  two  silk  ligatures  which  lead  into  two  small 
pouches." 

The  fact  that  both  of  these  experiments  succeeded  notwithstanding  that, 
in  each,  stitches  had  been  passed  into  the  lumen  of  the  intestine  or  of  the 
stomach,  makes  it  more  than  probable  that  Kaiser  is  not  the  only  one  who, 
in  spite  of  an  imperfect  technique,  has  had  good  results. 

The  experiments  of  mine  to  which  I  particularly  wish  to  invite  attention 
are  those  of  Group  II.  In  all  of  the  operations  of  this  group  the  plain-quilt 
submucosa  stitches  were  employed  for  the  complete  row;  and  in  most  of 
them  a  few  presection  buried-knot  (vide  Fig.  17  and  Group  III)  quilt 
stitches  were  taken  in  addition. 

Group  II.  Plain-Quilt  Submucosa  Stitches 

Experiment  1. — Large,  black-and-tan  dog.  Operation  January  25,  1887. 
Double  circular  suture :  to  reverse  about  one  foot  of  intestine."  Irrigation 
with  solution  of  corrosive  sublimate,  1 :  10,000.  Glass-slide  clamps.  Suture. 
Seven  presection  stitches  in  incomplete  first  row;  and  ten  plain-quilt  (post- 
section)  stitches  in  second  row.  Intestine  well  washed  with  warm  water  just 
before  being  replaced. 

January  20th. — Dog  wags  his  tail,  but  otherwise  rather  quiet. 

February  1st. — Very  lively,  and  seems  perfectly  well. 

Sth. — Dog  continues  to  be  well. 

27th  (about  five  weeks  after  the  operation). — Has  been  losing  appetite 
and  spirits  for  a  week  or  more.  Killed.  Autopsy:  Both  circular  sutures 
perfectly  healed — adhesions  not  nearly  so  extensive  as  in  Experiment  8 
(Group  I),  the  successful  "  Etagennaht "  loop  case.  The  further  descrip- 
tion of  the  autopsy  is  reserved  for  another  purpose. 

18  Kaiser:    Beitriige  zur  Operativen  Chirurgie  (Czerny),  1S7S,  p.  142. 
,T  Vide  Experiment  C. 


CIRCULAR  SUTUEE  OF  THE  INTESTINE  195 

Experiment  2. — Large,  black  Newfoundland  bitch.  Operation  Febru- 
ary 28th.  Double  circular  suture :  to  reverse  one  foot  of  intestine.  Very 
free  irrigation  with  solution  of  corrosive  sublimate  of  uncertain  strength — 
probably  1 :  1000.  Suture,  sublimate  silk.  Five  presection  stitches — one 
complete  row  of  plain-quilt  postsection  stitches. 

March  2d. — Dog  found  dead.  Autopsy,  by  Dr.  Mall :  Absolutely  no  peri- 
tonitis and  no  adhesions.  Lines  of  suture  perfectly  firm.  Unmistakable 
evidences  of  too  much  irrigation,  and  with  a  too  strong  solution  of  corrosive 
sublimate.  Ulcers  of  mucous  membrane  of  stomach.  Subperitoneal  haemor- 
rhages— particularly  over  bladder,  etc. 

Experiment  3. — Very  large,  black  Newfoundland  dog.  Operation 
March  4,  1887.  Double  circular  suture:  to  reverse  one  foot  of  intestine. 
Irrigation  with  solution  of  corrosive  sublimate,  1 :  20,000.  Considerable  con- 
tamination of  sutures  and  intestines  with  faeces  throughout  the  operation. 

March  6th. — Dog  so  savage  that  no  one  can  enter  the  room  in  which  he  is 
confined. 

April  1st. — Dog  has  not  had  a  bad  symptom  since  the  operation. 

May  7th. — Killed.  Autopsy  made  by  Dr.  Welch,  who  writes  me  that  the 
dog  "  was  very  weak  and  emaciated,  and  could  not  have  lived  much  longer. 
We  found  the  same  condition  of  things  as  in  the  other  case.18  There  was  a 
mass  of  solid  material,  made  up  mostly  of  bits  of  straw,  wood,  and  hair, 
which  formed  a  firm  impaction,  beginning  above  and  extending  an  equal 
distance  below  the  upper  suture,  but  not  reaching  down  more  than  halfway 
between  the  two  sutures.  The  intestine  was  much  distended  at  the  seat  of 
the  impaction  and  also,  although  to  a  less  extent,  above  the  impaction. 
There  were  very  few  adhesions.  The  peritonaeum  was  clean,  and  the  intes- 
tine beautifully  healed  at  the  site  of  the  sutures — the  inner  surface  being 
perfectly  smooth." 

Experiment  4. — Moderately  large,  yellow  dog.  Operation  February  19, 
1887.  Single  circular  resection  and  circular  suture.  Irrigation  with  solution 
of  corrosive  sublimate,  1 :  20,000.  Suture,  sublimate  silk.  Six  presection 
buried-knot  quilt  stitches,  and  one  complete  row  of  postsection  plain-quilt 
stitches. 

February  20th. — Dog  moderately  lively. 

March  11th. — Perfectly  well.  Killed  to  make  injection  of  liver.  Autopsy: 
Suture  perfectly  healed.   A  very  few  slight  adhesions. 

Experiment  5. — Large,  white  dog.  Operation  March  5,  1887.  Single 
circular  resection  and  circular  suture.  1.  Application  of  seven  presection 
buried-knot  quilt  sutures.  2.  Ligation  of  vessels  by  circumvection  ("  Um- 
stechung").  3.  Application  of  clamps.  4.  Section  of  intestine  very  close 
to  presection  stitches.  5.  Tying  of  presection  stitches.  6.  Application  of 
plain-quilt  stitches  (rather  too  far  from  cut  edge  of  intestine).  7.  Tying 
of  plain-quilt  stitches. 

March  11th. — Dog  seems  perfectly  well.  Killed  to  make  injection  of 
vessels  of  circular  suture.  Autopsy:  Slight  local  peritonitis  starting  from 
a  small  necrotic  ulcer  (ulcer  has  not  perforated  gut  wall — is  rather  super- 

M  Experiment  1,  Group  II. 


196  CIRCULAR  SUTUKE  OF  THE  INTESTINE 

ficial)  very  near  the  mesenteric  border,  at  line  of  circular  suture.  This  ulcer 
proceeded  undoubtedly  from  strangulation  where  the  stitches  (both  rows) 
were  closest  together. 

Experiment  6. — Large,  yellow  dog.  Operation  March  8,  1887.  Single 
circular  resection  and  circular  suture.  Intestine  cut  very  close  to  presection 
stitches.  Postsection  plain-quilt  sutures  applied  nearer  than  usual  to  the 
presection  stitches. 

March  25th. — Dog  has  had  no  bad  symptoms  since  the  operation.  Killed. 
Autopsy:  No  adhesions,  except  a  very  delicate  attachment  of  omentum  to 
line  of  suture,  anteriorly. 

Experiment  7. — Small,  shaggy,  yellow  dog.  Operation  March  8,  1887. 
Single  circular  resection  and  circular  suture.  A  few  presection  stitches ;  one 
complete  row  of  postsection  plain-quilt  stitches. 

March  IJfth. — Dog  has  made  an  uninterrupted  recovery.  Used  for  a  second 
experiment  for  another  purpose.  Killed.  Autopsy:  No  adhesions.  Circular 
suture  beautifully  healed,  but  so  much  intestinal  wall  had  been  turned  in 
that  some  obstruction  had  been  caused — manifested  by  conical  dilatation  of 
intestine,  and  accumulation  in  it  of  hay,  on  the  proximal  side  of  the  suture. 

This  case  is  one  of  several  which  indicate  that  it  is  not  advisable  to  make 
two  rows  of  stitches  on  small  dogs. 

Experiment  8. — Very  large,  brown  dog.  Operation  March  14,  1887. 
Single  circular  resection  and  circular  suture.  A  few  presection  and  one  com- 
plete row  of  postsection  sutures.  Operation  performed  without  an  assistant, 
and  without  the  employment  of  antiseptics.  No  clamps.  Irrigation  with  a 
solution  of  common  salt,  0.6  per  cent.,  at  37°  Cent. 

March  25th. — Dog  has  made  an  uninterrupted  recovery.  Killed.  Autopsy: 
No  adhesions — not  even  of  omentum  to  the  line  of  the  suture.  A  very  perfect 
result. 

This  operation  was  performed  without  any  antiseptic  precautions,  and 
without  an  assistant;  and  yet,  as  the  autopsy  showed,  the  result  could  not 
have  been  more  perfect. 

Experiment  9. — Rather  large,  black  and  white  dog.  Operation  March  18, 
1887.  Single  circular  resection  and  circular  suture.  A  few  presection  and 
one  complete  row  of  postsection  stitches.  Even  less  attention  paid  to  cleanli- 
ness than  in  the  preceding  experiment :  for  the  dog  was  operated  upon  to 
furnish  situations  from  which  to  make  drawings.  About  one  foot  of  intes- 
tine was  exposed  outside  of  the  abdominal  cavity  for  more  than  two  hours ; 
and  when  returned  was  very  blue  and  much  swollen.  But  the  sewing  was 
very  carefully  and  satisfactorily  done. 

April  1st. — Dog  is  very  lively,  and  seems  well.  Used  by  Dr.  Mall  for 
another  operation.  Killed.  Autopsy:  Intestinal  wound  firmly  healed,  but 
the  intestines,  at  the  site  of  the  suture,  are  matted  together. 

It  is  not  strange  that  the  intestines  should,  in  this  case,  have  been  matted 
together;  but  rather  to  be  wondered  at  that,  under  the  circumstances,  the 


CIECULAE  SUTUEE  OF  THE  INTESTINE  197 

dog  could  have  made  even  such  a  recovery,  indifferent  as  it  appears  from 
our  present  point  of  view. 

Experiment  10. — Large,  black  dog.  Operation  March  17,  1887.  Single 
circular  resection  and  circular  suture.  Operation  without  antiseptics  and 
without  clamps.  Suture.  A  few  presection  and  one  complete  row  of  post- 
section  stitches.  The  silk  was  so  very  old  that  it  broke  often  on  tying,  and 
many  of  the  stitches  had  to  be  retaken.  I  am  quite  sure  that  one — possibly 
two — of  the  stitches  were  passed  into  the  lumen  of  the  gut.  More  than  one 
foot  of  intestine  allowed  to  remain  outside  of  the  abdominal  cavity  for  one 
and  three-quarter  hours.  'The  dog  had  tapeworm  and  much  faeces  in  his  in- 
testine, so  that  there  was  a  good  opportunity  for  contamination  of  the  wound 
and  of  the  abdominal  cavity.  Very  free  irrigation,  during  and  after  the 
completion  of  the  circular  suture,  with  a  warm  salt  solution — 0.6  per  cent. 
Should  this  case  recover,  I  shall  regard  it  as  very  strong  evidence  in  favor  of 
my  suture. 

April  2d. — Dog  lively,  and  apparently  well.  Dr.  Mall  killed  the  dog,  subse- 
quently, and  appended  the  following  to  the  history :  Autopsy:  "  No  perito- 
nitis. Suture  fully  healed.  A  large  worm  {Eustrongylus  gigas),  alive  and 
active,  found  in  the  peritonaeal  cavity." 

Experiment  11. — Eather  large,  white  bitch.  Operation  February  1,  1887. 
Single  circular  resection  and  circular  suture.  One  complete  row  of  plain- 
quilt  submucosa  stitches  (vide  Fig.  22)  applied  before  and  tied  after  resect- 
ing about  half  an  inch  of  intestine.  I  found  the  taking  of  these  stitches  very 
easy,  but  to  resect  the  gut  under  them  was  somewhat  troublesome.  The 
method,  on  the  whole,  is  a  moderately  rapid  one — occupying  about  forty 
minutes. 

February  2d. — Dog  doing  nicely. 

26th. — Dog  perfectly  well.  Killed.  Autopsy:  No  adhesions.  A  most  per- 
fect result. 

It  will  be  observed  that  in  this  (the  foregoing)  case,  as  well  as  in  all 
of  the  following  cases  of  this  group,  the  incomplete  row  of  presection  stitches 
was  omitted ;  and  that  but  one  row  of  stitches  was  employed  for  the  circular 
suture. 

Experiment  12. — Very  large,  olive-brown  dog.  Operation  February  1, 
1887.  Eesection  of  two  feet  of  intestine.  I  made,  at  first,  a  circular  suture 
of  Emmert's  stitches  (vide  Fig.  23);  then,  being  dissatisfied  with  the 
appearance  of  the  suture,  I  again  resected  the  intestine  and  applied  one 
complete  row  of  plain-quilt  stitches. 

February  2d. — Dog  convalescent. 

3d. — Dog  lively,  and  apparently  well. 

March  9th. — Still  perfectly  well.  Killed.  Autopsy:  No  peritonitis,  and 
absolutely  no  adhesions. 

The  intestinal  wound  had  healed  so  perfectly  that  its  site  was  only  dis- 
covered after  Dr.  Mall  and  I,  in  search  of  the  suture  line,  had  run  the  intes- 
tine several  times  through  our  fingers. 


198  CIRCULAR  SUTURE  OF  THE  INTESTINE 

Experiment  13. — Small,  shaggy,  black  dog.  Operation  February  14, 
1887.  Circular  resection  and  circular  suture.  One  complete  row  (eighteen 
stitches)  of  plain-quilt  stitches.  Irrigation  with  tepid  salt  (0.6  per  cent) 
solution,  and,  sparingly,  while  tying  stitches,  with  a  solution  of  corrosive 
sublimate — 1 :  20,000. 

February  15th. — Dog  is  quiet — still  affected  by  morphine. 

16th. — Dog  is  very  playful. 

March  10th. — Perfectly  well.  Killed.  Autopsy:  Circular  suture  per- 
fectly healed.  Slight  adhesion  of  the  omentum  to  the  line  of  the  suture. 

Experiment  14. — Very  small,  old,  black  and  tan  bitch.  Operation  Feb- 
ruary 21,  1887.  Circular  resection  and  circular  suture.  One  row  of  plain- 
quilt  presection  sutures  (vide  Fig.  22).  Intestine  very  small;  the  smallest, 
I  think,  that  I  have  ever  sutured. 

March  7th. — Dog  has  been  doing  fairly  well  ever  since  the  operation,  but 
has  refused  food  for  a  day  or  two. 

March  9th. — Found  dead.  Autopsy:  No  peritonitis.  Near  the  site  of  the 
circular  suture  the  gut  is  found  to  be  much  twisted,  and  bound  in  this  posi- 
tion by  adhesions,  in  themselves  very  trivial.  Above  the  twist  the  intestine 
is  very  much  dilated.  Death  from  ileus.  The  suture  is  most  beautifully 
healed,  even  to  mucous  membrane  inclusive. 

Experiment  15. — Large,  brown  and  white  bitch.  Operation  March  3, 
1887.  Circular  resection  and  circular  suture.  One  complete  row  of  plain- 
quilt,  postsection  stitches.  Glass  clamps.  Irrigation  with  1 :  12,000  corrosive 
sublimate  solution. 

March  14th. — Dog  has  made  an  uninterrupted  recovery.  Given  to  the 
janitor  for  a  pet. 

June  1st. — Dog  perfectly  well. 

Although  there  were  but  fifteen  experiments  in  this  group,  they  include 
eighteen  circular  sutures  of  the  intestine,  all  of  which  were  successful.  In 
three  instances,  about  one  foot  of  intestine  was  reversed,  and  a  double  cir- 
cular suture  required.  Furthermore,  the  making  of  two  circular  sutures  at 
one  time,  particularly  when  accompanied  with  reversal  of  a  portion  of  the 
intestine,  increases  more  than  twofold  the  danger  to  the  animal  operated 
upon. 

But  what  chiefly  distinguishes  these  results,  is  the  absence  of  adhesions. 
In  five  of  the  experiments  (2,  7,  8,  11,  and  12)  there  were  absolutely  no 
adhesions;  nor  were  there  any  such  in  Experiments  6  and  13,  save  the  slight 
ones  between  the  omentum  and  the  face  of  the  line  of  the  suture.  In  only 
one  instance  were  the  intestines  matted  together  as  described  by  Ryd}'gier 
and  other  surgeons,  and  as  seen  by  me  in  so  many  of  my  earlier  experiments. 
They  who  have  attempted  double  circular  resection  and  double  circular 
suture  can  best  appreciate  the  magnitude  of  the  operation  of  reversing  a 
portion  of  the  intestine,  and  can  understand,  perhaps,  my  great  faith  in  the 
suture  which  has  given  such  results.    Experiments  8,  9,  and  10  were  per- 


CIRCULAR  SUTURE  OF  THE  INTESTINE  199 

formed  without  clamps,  without  antiseptics — except  for  the  silk,  which  had 
been  prepared  in  the  usual  way — and  without  especial  attention  to  cleanli- 
ness, save  that  the  intestinal  wound  was  diligently  washed  with  a  warm  salt 
solution  while  the  stitches  were  being  tied.  It  may  be  asked  why  adhesions 
should  be  so  strongly  objected  to.  Not  so  much  to  the  adhesions  as  such  is 
it  objected — although  we  have  seen  and  already  called  attention  to  the  fatal 
consequences  of  the  obstruction  which  may  attend  them — as  to  the  imperfect 
technique  which  constantly  admits  of  the  matting  together  of  the  intestines. 

Adhesions  of  this  nature  imply  inflammation;  and  an  inflammation  of 
an  extent  which,  though  it  may  not  usually  prove  disastrous,  is  always  more 
or  less  dangerous.  The  less  extensive  the  inflammation,  the  greater  the 
certainty  that  the  suture  will  hold.  It  cannot,  fairly,  be  urged  that  time 
may  have  swept  away  the  adhesions  in  my  cases,  for  the  autopsies,  at  which 
no  adhesions  at  all  were  found,  were  made  two  (Experiment  2),  six  (Experi- 
ment 7),  eleven  (Experiment  8),  twenty-five  (Experiment  11),  and  thirty- 
six  (Experiment  12)  days  after  the  operations. 

It  is  believed  that  the  method  of  operation  adopted  in  the  experiments  of 
Group  II  combats  more  satisfactorily  than  any  hitherto  suggested  the  dan- 
gers which  naturally  attend  suture  of  the  intestine.  The  great  danger  to 
be  apprehended  is,  as  already  mentioned,  the  development  of  suppurative 
peritonitis  as  the  result  of  the  operation. 

Let  us  consider  for  a  moment  the  various  factors  which  during  or  after 
the  operation  of  intestinal  suture  may  lead  directly  or  indirectly  to  the 
production  of  purulent  peritonitis.  In  judging  of  the  efficacy  of  the  factors 
we  are  guided  by  the  results  of  the  experiments  mentioned  in  the  beginning 
of  this  article. 

In  the  first  place,  whence  may  the  pyogenic  substances  come  which  are 
essential  to  the  production  of  suppurative  peritonitis  ?  Evidently  either  from 
outside  of  the  body  through  the  wound  in  the  abdominal  wall  or  from  the 
intestine  through  the  wound  in  its  coats.  There  is,  of  course,  no  especial 
danger  of  infection  of  the  peritonaeal  cavity  from  the  exterior  in  the  per- 
formance of  enterorrhaphy,  as  compared  with  other  operations  requiring 
laparotomy.  This  is  not  a  danger,  therefore,  which  needs  any  especial  con- 
sideration in  this  connection  or  which  is  to  be  regarded  as  serious. 

The  chief  danger  of  infection  of  the  peritonaeal  cavity  is  manifestly  from 
the  contents  of  the  intestine,  in  case  they  find  their  way  through  the  wound 
in  the  intestine  or  along  the  lines  of  suture.  There  is  a  possibility  of  the 
escape  of  intestinal  contents  at  the  time  of  the  operation,  but  this  is  a  danger 
which  can  be  readily  guarded  against  and  one  which  is  much  less  likely  to 
be  attended  by  serious  results  than  the  escape  of  intestinal  contents  into 
the  peritonaeum  subsequent  to  the  operation.    Probably  too  much  impor- 


200  CIRCULAR  SUTURE  OF  THE  INTESTINE 

tance  has  been  attached  to  the  use  of  antiseptic  solutions  for  irrigation  in 
intestinal  resection  (vide  Experiments  8,  9,  10,  and  13). 

Although  in  performing  enterorrhaphy  on  the  human  being  I  should  be 
unwilling  to  discard  what  seems  undoubtedly  to  be  an  additional  precaution, 
I  should,  in  the  light  of  my  experiments,  and  of  several  of  my  operations, 
hesitate  to  employ  solutions  as  strong  as  those  commonly  advised. 

We  are  brought,  therefore,  to  the  conclusion  that  the  chief  danger  of  infec- 
tion of  the  peritonaeum  is  from  the  passage  of  the  intestinal  contents  (bac- 
teria) into  the  peritonaeal  cavity  subsequent  to  the  operation.  The  conditions 
which  may  lead  to  this  unfortunate  occurrence  are  (1)  failure  to  close  com- 
pletely and  firmly  the  wound  of  the  intestine;  (2)  penetration  of  the  intes- 
tinal lumen  by  one  or  more  sutures;  (3)  giving  way  of  the  sutures;  (4) 
ulceration  or  sloughing  of  the  intestine  at  the  site  of  suture. 

In  order  to  bring  about  complete  and  firm  closure  of  the  abnormal  opening 
into  the  intestine  it  has  been  customary  to  make  several  series  of  sutures  of 
the  intestine  one  over  the  other  in  the  form  of  the  so-called  "  Etagennaht." 
In  this  way  a  considerable  extent  of  the  intestinal  wall  is  folded  in,  the 
circulation  of  which  is  greatly  impeded.  There  are  especial  dangers  which 
attend  the  folding  in  of  an  unnecessarily  large  amount  of  intestinal  wall, 
for,  on  the  one  hand,  this  increases  the  extent  of  tissue  which  undergoes 
sloughing  and  thus  increases  the  danger  of  infection,  and,  on  the  other  hand, 
the  flange  formed  by  the  folds  projecting  into  the  intestinal  lumen  is  an 
obstacle  to  the  passage  downward  of  the  faeces,  which,  accumulating  at  and 
above  the  site  of  suture,  increase  the  tension  upon  the  sutures  and  endanger 
their  separation. 

Experiments  will  subsequently  be  described  which  show  that  these  dangers 
are  not  imaginary,  but  real.  A  sufficiently  firm  closure  of  the  wound  in  the 
intestine  with  much  less  danger  from  the  sources  mentioned  is  accomplished 
by  the  method  adopted  in  the  experiments  of  Group  II,  and  which  will  be 
described  subsequently. 

Although  experiments  have  already  been  cited  which  show  the  possibility 
of  recovery  even  when  stitches  in  the  final  row  of  sutures  have  penetrated 
the  lumen  of  the  intestine,  nevertheless,  it  is  plain  that  this  penetration  of 
the  intestinal  lumen  is  an  accident  which  may  lead  to  serious  consequences, 
and  it  is  to  be  carefully  avoided.  While  it  has  been  the  aim  of  previous 
operators  to  avoid  this  accident,  no  definite  rules  have  been  laid  down  by 
which  this  is  to  be  accomplished.  I  wish,  therefore,  in  this  connection  to 
lay  especial  emphasis  upon  the  importance  of  appreciating,  as  can  be  done 
in  the  manner  already  described,  the  moment  when  the  point  of  the  needle 
comes  into  contact  with  the  submucous  coat  of  the  intestine.   By  observing 


CIRCULAR  SUTURE  OF  THE  INTESTINE  201 

this,  it  is  within  our  power  so  to  guide  the  needle  that,  while  including  a 
bit  of  submucous  tissue,  it  does  not  penetrate  the  mucous  coat. 

Of  no  less  importance  in  guarding  against  the  third  danger  of  peritonaeal 
infection  from  intestinal  contents,  is  care  that  each  stitch  in  the  final  row 
shall  include  a  bit  of  submucous  tissue.  Utterly  misleading  is  the  usual 
direction,  that  the  stitches  shall  include  only  serous  membrane,  or  even 
serous  membrane  and  muscular  coat.  Experiment  A  was  given  precedence 
in  the  list  of  the  experiments  described  in  this  article,  in  order  to  give 
prominence  to  the  fallacious  character  of  this  direction.  Any  one,  by  a 
simple  experiment,  can  convince  himself  how  frail  is  the  hold  of  sutures 
which  include  only  serosa  and  muscularis.  I  am  inclined  to  regard  per- 
foration of  the  gut -wall,  on  the  one  hand,  and  the  tearing  out  of  stitches,  on 
the  other,  as  the  leading  factors  in  the  production  of  the  peritonitis  which 
has  brought  about  the  fatal  issue  in  many  cases  of  intestinal  suture. 

The  occurrence  of  ulceration  or  necrosis  of  the  intestinal  wall  at  the  seat 
of  suture,  is  a  danger  which  is  twofold  in  its  action.  It  renders  possible  the 
escape  of  intestinal  contents,  and  it  affords  a  soil  suitable  for  the  lodgement 
and  growth  of  bacteria.  How  important  is  the  latter  factor  has  been  made 
apparent  by  the  experiments  of  Grawitz  previously  cited.  Especial  dangers 
attend  necrosis  of  the  serous  and  subjacent  coats  of  the  intestine,  even  when 
the  necrosis  does  not  extend  to  the  mucous  membrane;  for,  doubtless,  in- 
testinal bacteria,  which  otherwise  would  prove  harmless,  may  reach  the 
diseased  tissue  and  find  suitable  conditions  for  their  development. 

We  must  not  forget  that  the  predisposition  to  infectious  inflammation 
is  necessarily  always  present  in  circular  suture  of  the  intestine,  and  lies 
in  the  interference  with  the  circulation  which  the  suture  causes,  but  it 
should  be  our  aim  to  reduce  this  predisposition  to  a  minimum.  The  circular 
suture  disturbs  the  circulation  both  directly  and  indirectly:  directly,  in  so 
far  as  the  stitches  produce  constriction  of  the  tissues  which  they  include; 
and  indirectly,  in  that  it  bends  a  portion  of  the  intestinal  wall  at  right  angles 
to  its  original  long  axis.  To  these  causes  of  disturbance  of  the  circulation 
is  to  be  added  the  pressure  from  above  of  the  contents  of  the  intestine  upon 
the  flange  which  is  projected  into  the  lumen  in  the  form  of  the  involuted 
intestinal  wall.  I  am  inclined  to  believe  that  this  projecting  flange  acts, 
perhaps,  less  as  a  cause  of  intestinal  obstruction  than  as  a  factor  predis- 
posing to  the  formation  of  adhesions,  which,  to  the  best  of  my  knowledge, 
have  seldom  been  absent  in  the  obstruction  cases.  It  has  seemed  to  me  that 
these  adhesions  have  been  particularly  luxuriant  when  too  much  tissue  has 
been  turned  in  by  the  circular  suture. 

The  results  which  were  obtained  in  the  series  of  experiments  constituting 
Group  II,  furnish  a  sufficient  answer  to  the  plea  that  it  is  desirable  to  turn 


202  CIECULAE  SUTTEE  OF  THE  INTESTINE 

in  over  a  large  extent  the  edges  of  the  intestinal  wound,  in  order  to  bring 
as  much  of  the  peritonaeal  surfaces  as  possible  into  contact.  As  has  been 
shown,  a  sufficiently  extensive  adaptation  of  peritonaeal  surfaces  to  each  other 
can  be  accomplished  without  inverting  an  excessive  amount  of  intestine,  and 
thus  with  less  impairment  of  the  vitality  of  the  intestine,  and  consequently 
less  predisposition  to  peritonitis. 

If  the  turning  in  of  tissue  predisposes  to  too  extensive  inflammation, 
perhaps  the  greatest  danger  of  turning  in  too  much  is  not  that  the  flap 
may  play  the  part  of  a  stricture,  but  that  the  circulation  at  the  site  of  the 
suture  may  be  so  much  interfered  with  that  union  will  not  take  place. 

Experiments  G  and  H  were  made  partlv  to  determine  if  this  were  so. 
and  partly  to  assist  in  establishing  my  belief  that  one  could  not.,  with  safety, 
invert  as  much  tissue  in  small  as  in  large  dogs. 

Expeei:ment  G. — Very  small,  brown  bitch.   Operation  March  •: . 
employ  two  rows  of  quilt  stitches  in  suturing  the  intestine  of  a  very  small 
animal. 

March  9th. — Died.  Autopsy:   Gangrene  of  inverted  edges.  No  union. 

Experiment  H. — Very  small,  black-and-tan  terrier  biteh.  Operation 
March  7.  1887.  To  employ  two  rows  of  quilt  stitches  in  suturing  the  intes- 
tine of  a  very  small  animal.  Intestine  so  small  that,  after  the  second  row  of 
stitches  was  tied,  the  gut  at  the  site  of  the  suture  looked  quite  white, 
especially  along  the  convex  border. 

March  11th. — Dog  not  well.  Killed.  Autopsy:  Gangrene  of  flap,  as  ex- 
pected.   Purulent  peritonitis. 

If  two  rows  of  stitches  are  so  dangerous  in  very  small  dogs,  why  use  pre- 
section  stitches  even  in  large  d<:  g  -  I 

This  question  leads  us  to  the  consideration  of  the  technique. 

Technique. — When  the  gut  has  been  completely  divided  there  ensues, 
immediately,  a  spasm  of  the  circular  muscle  fibres  nearest  the  cut  edges, 
which  inverts  the  mucous  membrane,  and  almost  closes  the  newly  made 
intestinal  orifices.  The  spasm  of  these  fibres  lasts  but  a  few  seconds : 
succeeded  by  a  relaxation  of  the  same,  and  by  a  contraction  of  the  adjacent 
circular  fibres ;  and  now  the  mucous  membrane  is  rolled  out.  It  is  exceed- 
ingly troublesome  to  take  the  stitches  properly  when  the  mucous  membrane 
is  thus  everted.  To  relieve  myself  of  this  annoyance.  I  devised  and  tested 
various  presection  stitches,  and,  finally,  adopted  the  one  represented  in 
Pig.  17. 

To  distinguish  it  from  the  other  forms  of  quilt  stitch,  I  have  called  it  the 
buried-knot  quilt  stitch. 

The  four  threads,  two  from  each  side,  are  tied  at  one  time,  and  the  knot 
becomes  buried  in  the  folds  which  have  been  raised  up  thereby.  From  five  to 


CIRCULAR  SUTURE  OF  THE  INTESTINE 

seven  presection  stitches — ten  to  fourteen  half -stitches — are  taken ;  two  of 
these  are  at  the  mesenteric  border,  one  on  each  side,  and  just  at  the  attach- 
ment of  the  mesentery.  The  needle  is  introduced  on  a  line  with  one  of  the 
radii  (vide  Fig.  16,  a)  of  a  transverse  section  of  the  intestine,  and  pressed 
upon  gently  by  the  pulp  of  one  finger  until  the  resistance  offered  by  the 
submucosa  is  encountered;  it  is  then  tilted  (vide  Fig.  16,  b)  through  ninety 
degrees,  or  until  about  parallel  with  the  long  axis  of  the  gut,  pressed  on  with 
a  little  more  force  than  before,  tilted  still  further,  and,  finally,  passed  out. 
It  is  reintroduced  almost,  but  not  precisely,  where  it  emerged  (vide  Fig.  It), 
passed  through  in  the  same  manner  as  before,  but  in  the  opposite  direction, 
and  its  thread  divided.  The  threads  of  the  half -stitches  from  both  sides. 
when  straightened  out,  naturally  cross  each  other,  and  lie  upon  the  portion 
of  intestine  to  be  resected.  There  is  an  opportunity  for  the  exercise  of  some 


Fig.  17. — Presection.  Buried-Knot  Quilt  Half-Stitches. 

discretion  in  the  selection  of  a  spot  on  the  mesenteric  border  for  the  intro- 
duction of  the  first  stitch.  The  vessels  distributed  to  the  intestine  are  en- 
sheathed  in  more  or  less  fat,  usually  in  enough  to  make  the  mesenteric  border 
obscure  except  at  certain  places  between  vessels  which  are  rather  far  apart. 
These  places  are  often  entirely  free  from  fat  and,  if  the  mesentery  be  not 
pulled  upon,  are  concave. 

At  the  bottom  of  any  one  of  these  little  concavities  (vide  Fig.  18)  the 
needle  can  be  introduced  with  greater  precision  than  it  could  be  at  a  point 
where  fat  obscures  the  mesenteric  border.  The  first  presection  stitch  (half- 
stitch),  so  taken,  can  be  seen  through  the  mesentery,  and  serves  as  a  guide 
for  the  taking  of  the  corresponding  stitch  (half -stitch)  on  the  other  side. 

I  sew  with  what  are  called  milliner's  needles.  These  needles  differ  from 
the  ordinary  cambric  needles,  only  in  that  they  are  disproportionately  long, 
and,  hence,  easier  to  handle.   Xos.  9  and  10  are  good  sizes  for  the  purpose. 


204 


CIRCULAR  SUTURE  OF  THE  IXTESTINE 


Finer  sizes  cannot  be  threaded  easily.  Black  silk  is  preferable  to  white 
because  it  contrasts  more  strongly  with  the  parts  to  be  sewed.  The  silk  was 
prepared  by  soaking  it — on  the  spool — in  a  solution  of  corrosive  sublimate, 
1 :  1000. 


Fig.  18. — Introduction  of  Xecdle  Into  Concavity,  Free  From  Fat,  in  Taking 
the  First  Presection  Stitch. 

When  all  the  presection  stitches  have  been  introduced,  the  vessels  of  the 
part  to  be  resected  are  ligated  (vide  Fig.  17,  x )  by  circumvection  with 
one  of  the  threaded  milliner's  needles.  Then  the  intestine  is  divided  as  close 
as  possible  to  the  presection  stitches  (vide  Fig.  19).  It  is  better  to  make  a 
circtilar  division  of  the  wall  of  the  intestine  than  to  cut  through  both  walls 
at  once.   By  cutting  rather  rapidly  one  can  take  advantage  of  the  first  mus- 


Fig.  19.— Intestine  Divided  Close  to  Presection,  Buried-Knot  Half-Stitches. 

cular  contraction,  and  can  complete  this  part  of  the  operation  before  eversion 
of  the  mucous  membrane  has  taken  place.  The  presection  stitches  being 
tied,  the  eversion  of  the  mucous  membrane  is  prevented  and  the  way  prepared 
for  the  application  of  the  complete  row  of  what  may  be  called  plain-quilt 
stitches  (vide  Fig.  20). 

The  plain-quilt  stitches  include,  like  the  presection  stitches,  threads  of 
the  submucosa,  and  should  be  placed  a  little  nearer  to  the  cut  edges  than 


CIRCULAR  SUTURE  OF  THE  INTESTINE  205 

Figs.  20  and  21  would  lead  us  to  suppose.  They  should  all  be  applied  before 
a  single  one  is  tied.  It  is  impossible  to  preserve  a  straight  line  of  application 
if  each  stitch  be  tied  as  it  is  taken — the  tendency  being  to  depart,  in  an 
outward  direction,  more  and  more  from  the  straight  line.  The  distance  from 
each  other  at  which  the  stitches  should  be  taken  cannot  be  given  at  once  for 
all  of  them — so  much  depends  upon  the  spasm  of  the  circular  muscle  fibres 
along  the  line  of,  and  caused  by  the  taking  of  the  stitches.  The  contraction 
does  not,  as  a  rule,  supervene  until  several  stitches  have  been  taken;  but, 


Fig.  20.— Presection,  Buried-Knot  Stitches  Tied;  Plain-Quilt, 
Postsection  Stitches  Introduced. 

once  set  up,  it  extends  in  a  circle  in  advance  of  the  stitches,  and  must  be 
taken  into  consideration  in  the  application  of  them.  Before  the  last  stitches 
have  been  applied  the  muscular  tissue  concerned  is,  frequently,  no  longer 
able  to  respond  to  the  stimulus  of  stitch-taking,  and  the  intestine  assumes 
its  natural  size.  During  the  period  of  muscular  contraction  the  stitches  must 
be  applied  very  close  to  one  another — perhaps  one  to  one  and  one-half  milli- 
metres apart — but  before  and  after  this  contraction  an  interval  of  two  to 


Fig.  21.— Intestine  After  All  but  Four  of  the  Plain-Quilt  Stitches 
Have  Been  Tied. 

two  and  one-half  millimetres  may  be  left  between  them.  The  wall  of  the  gut 
rolls  in  of  itself  as  the  stitches  are  tied  (vide  Fig.  21),  and  the  entire  opera- 
tion can  be  conveniently  performed  without  an  assistant.  The  threads  must 
not  be  drawn  so  tightly  in  tying  as  to  make  the  tissue  included  in  the  stitch, 
look  very  anaemic. 

In  five  of  my  operations  (Experiments  11,  12,  13,  14,  15,  Group  II)  the 
incomplete  row  of  presection  stitches  was  not  employed ;  and,  although  the 
results  justify  the  belief  that  it  may  with  safety  be  omitted,  the  operation  is 
so  greatly  facilitated  by  its  use  that  I  should  be  sorry,  without  good  reason, 
to  discard  it. 


206  CIRCULAR  SUTURE  OF  THE  INTESTINE 

In  no  instance  was  a  triangular  piece  of  mesentery  exsected;  nor  did  I 
ever  sew  together  the  edges  of  the  rent  which  was  always  made  in  the  mesen- 
tery, for  fear  of  including  vessels  which  might  contribute  to  the  blood  supply 
of  the  sutured  parts. 

Irrigation. — The  fluid  used  for  irrigation,  if  neither  too  strong  nor  too 
hot,  seemed  to  have  little  or  no  influence  upon  the  results.  A  solution  of 
corrosive  sublimate — 1 :  20,000 — was  the  one  commonly  employed,  and  I 
should  prefer  a  weaker  (1 :  30,000  to  1 :  40,000)  solution  to  a  stronger. 

We  had  the  opportunity,  repeatedly,  to  observe  the  immediate  bad  effects 
on  the  intestine  of  solutions  hotter  than  38°  Centigrade;  and  ultimately 
I  became  partial  to  cold  or  slightly  tepid  solutions  for  irrigation,  because, 
with  the  use  of  them,  the  wall  of  the  intestine  did  not  become  so  much 
swollen,  and  the  stitches  could,  therefore,  be  applied  with  greater  precision. 

I  was  always  especially  careful  to  have  the  wound  freely  irrigated  during 
the  tying  of  each  knot,  and  thus  precluded  the  possibility  of  imprisoning 
foreign  matter  between  the  opposed  peritonaeal  surfaces. 

Clamps. — The  intestine  was  usually  clamped  with  glass  microscopical 
slides  of  the  English  pattern ;  first  made  to  embrace  the  gut,  they  were  then 
tied  together  about  their  middle  by  a  disinfected  string;  lastly,  a  short 
piece  of  rubber-tubing  was  introduced,  on  the  stretch,  between  the  con- 
verging ends  of  the  slides ;  and,  by  slipping  the  tubing  toward  or  away  from 
the  string,  the  pressure  exercised  by  the  clamp  could  be  diminished  or  in- 
creased. Aside  from  its  simplicity  and  the  readiness  with  which  it  can  be 
applied,  the  clamp  has,  in  addition,  this  in  its  favor,  that  through  its  glass 
blades  the  state  of  the  circulation  in  the  intestinal  wall  may  be  watched. 

Abdominal  Wound. — The  incision  was  always,  save  once,  made  in  the 
linea  alba,  and  as  near  to  the  pubes  as  practicable.  If  it  was  carried  too  far 
in  the  direction  of  the  xiphoid  cartilage,  we  were  annoyed  by  the  protrusion 
of  a  fatty  flap  covered  by  peritonaeum,  which  seemed  to  spring  from  the 
posterior  surface  of  the  lower  piece  of  the  sternum  and  from  the  upper  part 
of  the  inner  surface  of  the  anterior  abdominal  wall. 

Before  cutting  through  the  peritonaeum  we  covered  the  dog  with  two 
large  disinfected  towels  (a  procedure  suggested  by  Dr.  Mall),  and  stitched 
them  to  the  edges  of  the  abdominal  wound  and,  above  and  below  it,  to  each 
other. 

The  abdominal  wound  was  closed  usually  with  two  rows  of  sutures.  The 
first  row,  made  with  interrupted  stitches  of  silkworm  gut,  included  every- 
thing but  the  skin.  The  cut  edges  of  skin  were  then  brought  loosely  together 
by  a  continuous  suture  taken  from  its  under  surface  and  from  the  under- 
lying loose  connective  tissue.  The  wounds  were  dressed  with  horsehair  taken 
from  a  corrosive  sublimate  solution,  1 :  1000,  and  were  bandaged  with 
crinoline. 


CIRCULAR  SUTURE  OF  THE  IXTESTIXE  207 

Preparation  and  Care  of  the  Dogs. — Only  one  of  the  dogs  operated 
upon  (Exp.  3,  Group  II)  was  dieted  before  the  operation,  or  isolated  after 
it.  The  dogs  were  frequently  fed  on  the  day  of  the  operation,  and  were 
always  allowed  to  run  about,  all  together  in  a  large  room,  as  soon  after  it  as 
they  might  be  inclined.  Milk  was  given  to  them  as  soon  as  they  would  take 
it,  but  solid  food  was  withheld  for  about  one  week. 

Anaesthetics. — Morphine,  hypodermatically  (5i-5iv  of  a  5  per  cent 
solution),  followed  by  a  few  inhalations  of  ether. 

Neither  Neuber's  intestinal  tubes  nor  any  other  similar  contrivances  were 
made  use  of  to  simplify  the  performance  of  circular  suture  of  the  intestine ; 
because,  (1)  they  were  not  believed  to  be  necessary;  and  (2)  it  was  thought 
that  they  would  increase  the  danger  of  the  operation. 

The  employment  of  an  incomplete  row  of  buried-knot  presection  stitches 
facilitates  the  application  of  the  subsequent  complete  row  quite  as  much  as 
does  the  use  of  the  Xeuber's  tube.  Furthermore,  when  a  Xeuber's  tube  is 
used,  an  incomplete  row  of  postsection  stitches  must  be  taken;  and,  as  we 
have  repeatedly  said,  the  application  of  first  row  postsection  stitches  is 
troublesome,  whereas  it  is  easy  to  apply  presection  stitches. 

I  believe  that  when  the  circular  suture  is  made  over  a  tube  of  any  kind 
the  circulation  in  the  immediate  neighborhood  of  and  along  the  line  of 
suture  is  additionally  obstructed.  And  should  the  tube  slip  to  the  slightest 
extent  out  of  place,  or  soften  too  quickly,  the  circular  intestinal  wound  may 
leak ;  for  I  have  repeatedly  observed  that  a  suture  which  answered  the  pur- 
pose over  a  tube  failed  to  close  the  wound  sufficiently  when  the  tube  was 
removed. 

The  Preparation  and  Preservation  of  the  Xeedles. — Madelung  and 
other  surgeons  have  called  attention  to  the  fact  that,  in  order  to  save  time 
at  the  operation,  it  is  well  to  have  the  needles  threaded  beforehand,  and 
hence,  to  have  a  method  of  protecting  the  disinfected,  threaded  needles  per- 
manently from  rusting.  Madelung  suggests  keeping  them  in  alcohol.  I  have 
tried,  among  other  fluids,  glycerine  and  alcohol,  and  found  both  of  them  too 
hygroscopic  for  the  purpose.  The  difficulties  seem  to  be  most  readily  met  by 
the  adoption  of  an  antiseptic  oil.  I  have  used  with  satisfaction  the  oil  of 
juniper  berries.  It  is,  furthermore,  necessary  to  have  a  means  of  supporting 
the  needles  in  the  oil,  and  above  the  water  with  which  the  oil  is,  from  the 
picking  up  of  the  needles  with  wet  fingers  or  wet  forceps,  sooner  or  later, 
certain  to  become  contaminated.  It  is  not  enough  to  place  the  needles  on 
a  wire-netting  supported  in  the  oil;  for  drops  of  water  will  surely  be  sus- 
tained at  the  points  where  the  needles  cross  each  other,  and  where  they  cross 
the  wires,  and  at  the  points  where  the  wires  interlace. 


208  CIRCULAR  SUTURE  OF  THE  INTESTINE 

Until  we  know  of  a  better  method  of  preserving  the  needles  for  immediate 
use,  I  would  suggest  the  following  one :  Thread  the  needles  with  dry  silk. 
Tie  the  silk  with  one  knot  in  the  eye  of  the  needle.  Bend  to  a  little  more 
than  a  half  cylinder  an  oblong  piece  of  very  fine  brass  wire-netting  on  its 
long  axis,  and  thrust  the  points  of  the  threaded  needles  through  the  netting 
along  the  line  of  its  greatest  convexity.  When  a  needle  has  been  passed 
almost  through  the  netting  wind  its  thread  about  the  half  cylinder  and  tie 
the  ends  of  the  thread  together  near  the  eye  of  the  needle.  When  all  the 
needles  have  been  introduced,  and  their  threads  wound  and  tied,  place  the 
wire-netting  thus  armed  in  a  cylindrical  jar  filled  with  the  oil  of  juniper 
berries.  Use  the  lowest  needles  first. 

It  certainly  would  be  a  great  gain  to  the  technique  if  such  presection  half- 
stitches  could  be  devised,  that  one  complete  row  of  them  on  each  side  of  the 


Fig.  22.— Plain-Quilt,  Presection  Stitches  Introduced. 

portion  of  intestine  to  be  resected  would  suffice  for  the  circular  suture. 
I  say  /ia?/-stitches  because,  though  the  application  of  complete  presection 
stitches  (vide  Fig.  22)  is  easy,  it  is  rather  annoying  to  resect  under  them 
and  to  arrange  them  for  tying  (vide  Experiments  11,  14,  and  15,  Group  II). 
I  have  tried  to  perform  circular  suture  of  the  intestine  with  presection 
ftaZ/-stitches — one  complete  row  of  them  on  each  side  of  the  portion  of  intes- 
tine (vide  Groups  III  and  IV) — and,  thus  far,  with  unsatisfactory  results. 


Group  III.  One  Complete  Row  of  Buried-Knot,  Presection 
Submucosa  Sutures 

(For  buried-knot  stitches,  vide  Fig.  17,  p.  203,  and  Fig.  20,  p.  205.) 

Experiment  1. — Small,  black  dog.  Operation  February  2,  1887.  To 
make  single  circular  suture  with  one  complete  row  of  presection,  buried- 
knot  stitches.  The  operation  lasted  three-quarters  of  an  hour  from  the  first 
cut  into  the  abdominal  wall  until  the  application  of  the  dressing.  Irrigation 
with  solution  of  corrosive  sublimate  of  uncertain  strength. 

February  Sd. — Dog  evidently  not  feeling  well. 


CIRCULAR  SUTURE  OF  THE  INTESTINE  209 

5th. — Found  dead.  Autopsy :  No  signs  of  inflammation  in  the  peritonaeal 
cavity;  not  even  at  the  site  of  the  suture.  Positive  evidences  of  corrosive 
sublimate  irritation  (vide  Experiment  2,  Group  II.  Autopsy). 

Experiment  2. — Small  skye-terrier.  Operation  February  2,  1887.  To 
make  a  single  circular  suture  with  one  row  of  buried-knot,  presection 
stitches.  The  operation  for  circular  suture  lasted  thirty-five  minutes.  Irriga- 
tion with  the  same  strong  corrosive  sublimate  solution  as  in  the  preceding 
case. 

February  3d. — Dog  found  dead.  Autopsy:  Subperitoneal  vascular  injec- 
tion and  haemorrhagic  extravasations.  Blood-tinged  fluid  in  the  peritonaeal 
cavity,  etc.  The  circular  suture  is  firm ;  holds  water  injected  with  sufficient 
force  to  distend  the  intestine.  Death  from  too  strong  an  irrigation  fluid. 

Experiment  3. — Rather  small  skye-terrier.  Operated  February  3,  1887. 
Same  suture  as  in  foregoing  cases.  Operation  performed  in  thirty-four 
minutes. 

February  8th. — Dog  is  dying.  Autopsy:  Purulent  peritonitis,  starting 
from  the  circular  suture. 

Experiment  4. — Small  fox-terrier.  Operation  February  4,  1887.  Same 
suture  as  in  foregoing  experiments  of  this  group.  Irrigation  with  solution 
of  corrosive  sublimate,  1 :  10,000. 

February  8th. — Dog  is  dying.  Killed.  Autopsy:  Purulent  peritonitis, 
starting  from  line  of  circular  suture. 

Experiment  5. — Medium-sized,  fox-terrier  bitch.  Operation  February  7, 
1887.  Same  suture  as  in  foregoing  experiments  of  this  group.  Irrigation 
with  ordinary  cold  water. 

February  21st. — Dog  is  failing.  Killed.  Autopsy:  Intestines  badly  mat- 
ted together  by  adhesions.  Circumscribed  abscess  cavity  surrounding,  almost 
completely,  the  circular  suture,  which  later  appeared  to  be  firmly  healed. 

Experiment  6. — Medium-sized,  jet-black  bitch.  Operation  January  27, 
1887.  To  reverse  a  portion  of  the  intestine.  Double  circular  suture.  Pre- 
section buried-knot  stitches.   Operation  lasted  one  and  three-quarters  hours. 

January  29th. — Dog  died.  Autopsy:  Purulent  peritonitis. 

Experiment  7. — Medium-sized  dog.  Operation  February  4,  1887.  To 
reverse  portion  of  intestine.   Operation  the  same  as  in  Example  6. 

February  9th. — A.  m.,  suddenly  taken  sick.  P.  m.,  died.  Autopsy:  Peri- 
tonitis.  Abdomen  distended  with  sero-purulent  fluid. 

Group  IV.  Emmert's  Stitches 

In  the  experiments  of  this  group  such  presection  stitches  were  applied 
as  are  represented  in  Fig.  23. 

The  idea  of  making  such  stitches  I  believed  to  be  original  with  me,  until 
I  ascertained  that  I  had  been  anticipated  in  the  conception  of  them  by 
15 


210  CIRCULAR  SUTTEE  OF  THE  IXTESTINE 

Emmert,"  who,  however,  had  employed  them  only  to  sew  up  linear  wounds 
of  the  intestine,  and  not  for  the  circular  suture. 

Experiment  1. — Operation  January  20,  1887.  Single  circular  suture  by 
one  complete  row  of  Emmert's  stitches. 

January  21st. — Dog,  evidently,  has  peritonitis. 

22d. — Found  dead.  Autopsy:  Suture  had  given  away.  Suppurative 
peritonitis. 

Experiment  2. — Large  pointer  dog.  Operation  February  9,  1887.  The 
same  suture  as  in  Experiment  1. 

February  11th. — Dog  found  dead.  Autopsy:  Purulent  peritonitis  start- 
ing from  the  circular  suture. 

Experiment  3. — Small  black-and-tan  dog.  Operation  February  11,  18S7. 
Single  circular  suture  (Emmert's  stitches)  as  in  Experiments  1  and  2. 

February  12th. — Dog  died.  Autopsy:  Purulent  peritonitis  starting  from 
the  circular  suture. 


Fig.  23.— Emmert's  Stitches. 

I  shall  not  record  the  rest  of  my  experiments  on  circular  suture  of  the 
intestine,  because  most  of  them  seem,  now,  rather  absurd  to  me,  and  none 
of  them  admit  of  classification. 

Summary 

1.  It  is  impossible  to  suture  the  serosa  alone,  as  advised  by  authors. 

2.  It  is  impossible  to  suture  unfailingly  the  serosa  and  muscularis  alone, 
unless  one  is  familiar  with  the  resistance  offered  to  the  point  of  the  needle 
by  the  coats  of  the  intestine.  Furthermore,  stitches  which  include  nothing 
but  these  two  coats  tear  out  easily,  and  are,  therefore,  not  to  be  trusted. 

3.  Each  stitch  should  include  a  bit  of  the  submucosa.  A  thread  of  this 
coat  is  much  stronger  than  a  shred  of  the  entire  thickness  of  the  serosa  and 
muscularis.  It  is  not  difficult  to  familiarize  one's  self  with  the  resistance 
furnished  by  the  submucosa,  and  it  is  quite  as  easy  to  include  a  bit  of  this 
coat  in  each  stitch  as  to  suture  the  serosa  and  muscularis  alone. 

4.  It  is  unnecessary  in  performing  circular  suture  of  the  intestine  to 
make  more  than  one  complete  row  of  stitches  if  they  be  of  the  plain-quilt 

"Emmert:   Pitha  and  Billroth's  Handb.  d.  Chirurgie,  Absch.  vii.  p.  209. 


CIECULAE  SUTUKE  OF  THE  INTESTINE  211 

variety.  Unless  all  of  the  stitches  of  the  row  are  applied  before  a  single  one 
is  tied,  it  is  impossible  to  preserve  a  straight  line  in  the  application  of  them. 

5.  It  facilitates  the  operation  very  much  to  make  five  or  six  presection 
sutures;  for  the  eversion  of  the  mucous  membrane,  which  otherwise  takes 
place  and  makes  the  application  of  first-row,  postsection  stitches  trouble- 
some, is  thus  prevented.  The  first  presection  stitches  should  be  introduced 
at  the  mesenteric  border  of  the  intestine,  and  at  a  place  as  free  from  fat  as 
possible. 

6.  The  plain-quilt  stitches  are  to  be  preferred  to  the  ordinary  Lembert's 
stitches  ( Knopf nahte)  because  (1)  one  row  of  them  (the  former)  is  suffi- 
cient for  the  circular  suture;  (2)  the  knots  of  the  first  row  of  Lembert's 
stitches  prevent  the  most  accurate  apposition  of  the  opposed  peritonaeal 
surfaces;  (3)  the  plain-quilt  stitches  constrict  the  tissues  less  than  the  Lem- 
bert's stitches;  and  (4)  the  former  tear  out  less  easily  than  the  latter. 
Madelung's  cartilage-plates,  which  he  employs  partly  to  prevent  the  tearing 
out  of  the  stitches,  are  unnecessary  when  a  bit  of  the  submucosa  is  taken  up 
with  each  stitch. 

7.  The  vessels  of  the  excised  intestine  should  be  ligated  by  circumvection 
("  Umstechung  ").  It  is  not  necessary  to  exsect  a  triangular  piece  of  mesen- 
tery; and  it  is  unadvisable  to  sew  together  the  edges  of  the  rent  in  the 
mesentery,  for,  in  so  doing,  one  might  include  small  vessels  which  contribute 
to  the  blood-supply  of  the  sutured  parts. 

8.  Solutions  of  corrosive  sublimate  stronger  than  1 :  20,000  should  not  be 
used  for  irrigation.  It  would  be  better,  perhaps,  to  employ  weaker  solutions 
(1:  30,000  or  1:  40,000).  The  irrigation  should  be  attended  to  most  dili- 
gently when  the  stitches  are  being  tied. 


INTESTINAL  ANASTOMOSIS  l 

We  have  killed  today  three  of  a  series  of  dogs  operated  upon  for  the  pro- 
duction of  intestinal  anastomosis.  The  results  are  so  gratifying  that  it  gives 
me  pleasure  to  be  able  to  show  to  you  the  first  specimens.  In  two  of  the 
specimens  there  are  no  adhesions ;  in  one  there  is  a  delicate  adhesion  at  one 
spot  between  the  omentum  and  the  line  of  suture. 

The  success  of  any  form  of  intestinal  suture  is  inversely  proportionate  to 
the  extent  of  the  adhesions  which  result  from  the  employment  of  the  par- 
ticular method.  The  method  which  we  employ  is  a  new  one.  The  success  of 
it  depends,  I  believe,  upon  the  appreciation  of  the  importance  of  the  sub- 
mucous coat  of  the  intestine.  It  is  remarkable  that  no  one  has  recognized 
the  important  part  which  this  coat  should  play  in  operations  for  intestinal 
suture ;  it  is  still  more  remarkable  that  surgeons  could  have  altogether  over- 
looked the  existence  of  the  submucosa;  and  it  is  perhaps  most  remarkable 
that  experimenters  and  writers  on  the  subject  of  intestinal  suture  should 
without  exception  believe  that  it  is  possible  to  take  a  stitch  of  the  peritonaeal 
coat  alone.  The  crude  views  of  Jobert  and  Lembert  as  to  the  construction 
of  the  wall  of  the  intestine  have  been  universally  accepted  by  surgeons  up 
to  the  present  time.  The  peritonaeal  coat  is  believed  to  be  thick  enough  and 
sufficiently  strong  to  hold  a  stitch  and  the  existence  of  the  submucous  coat 
has  been  ignored. 

About  three  years  ago  I  endeavored  to  emphasize  the  importance  of  the 
submucous  coat  in  operations  upon  the  intestine  a  but  only  succeeded  in  at- 
tracting attention  to  the  quilt  or  square  stitch  which  I  still  employ  in  all 
sutures  of  the  intestine. 

The  peritonaeum  is  so  thin  that  one  cannot  represent  it  by  the  finest  pencil 
stroke  unless  the  wall  of  the  intestine  be  magnified  to  a  thickness  of  about 
5  cm. ;  vid  Fig.  16.  It  is  absurd  therefore  to  speak  of  a  stitch  of  the  serosa. 
A  stitch  which  includes  only  the  peritonaeal  and  muscular  coats  is  a  very 
weak  and  unreliable  one.  The  submucosa  is  an  exceedingly  tough  coat.  A 
thread  of  it  is  sufficient  to  insure  the  safety  of  the  stitch.  Each  stitch  should 
include  at  least  a  thread  or  two  of  the  submucosa.  If  the  submucosa  be  per- 
forated the  intestinal  lumen  is  almost  certainly  entered;  vid.   Fig.   16. 

1  Presented  before  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  Decem- 
ber 1,  1890. 
Johns  Hopkins  IIosp.  Bull.,  Bait.,  1891,  ii,  1-4.  (Reprinted.) 
■The  American  Journal  of  the  Medical  Sciences,  October,  18S7. 
212 


INTESTINAL  ANASTOMOSIS 


213 


Sufficient  resistance  is  offered  to  the  point  of  a  needle  by  the  submucosa  to 
enable  one  with  a  very  little  practice  to  recognize  this  coat  as  soon  as  it  is 
encountered  and  to  take  up  a  small  bit  of  it  without  entering  the  lumen  of 
the  intestine. 

Allow  me  to  demonstrate  to  you  the  submucosa  and  then  the  method  by 
which  one  may  with  certainty  catch  up  a  small  shred  of  the  submucosa  with- 


Fig.  24. — Posterior  Row  of  Sutures  Applied. 

out  perforating  this  coat  of  the  intestine.  To  isolate  the  submucosa,  engage 
the  intestine  firmly  between  the  handles  of  a  scissors  and  pull  the  intestine, 
thus.  The  handles  allow  nothing  but  the  submucous  coat  to  pass  between 
them.  The  serous  and  muscular  coats  are  being  stripped  off  as  you  see  from 
the  outer  side,  and  the  mucous  coat  which  you  cannot  see  is  being  stripped 
off  from  the  inner  side  of  the  submucosa.  You  will  observe  when  I  inflate 
the  submucosa  that  it  has  not  been  torn  by  this  rough  manipulation.   I  now 


214 


INTESTINAL  ANASTOMOSIS 


catch  up  a  fine  shred  of  it  with  this  threaded  needle.  Please  test  the  strength 
of  this  shred  by  pulling  the  loop  of  thread  which  passes  under  it.  If  the 
cotton  thread  were  not  so  heavy  it  is  doubtful  which  would  be  broken,  the 
cotton  thread  or  the  shred  of  the  submucosa.  The  stitch  which  I  am  now 
taking  includes  the  serous  and  both  muscular  coats  but  not  the  submucosa. 
You  will  observe  that  the  thread  tears  through  the  muscle  about  as  easily 
as  it  would  through  putty. 


Fia.  25. — Posterior  Row  of  Sutures  Tied.  Lateral  Sutures  Applied,  but  Not  Tied. 

With  a  fresh  piece  of  intestine  let  me  prove  to  you  that  one  can  with  cer- 
tainty pick  up  with  each  stitch  a  thread  of  the  submucosa  without  entering 
the  lumen  of  the  intestine.  This  is  a  fine  milliner's  needle  which  I  am  using. 
The  point  of  it  has  now  passed  through  the  muscular  coats  and  I  feel  dis- 
tinctly the  resistance  offered  to  it  by  the  submucosa.  The  needle  should  be 
introduced  by  pressing  on  its  blunt  end  with  the  pulp  of  one  of  the  fingers. 
If  the  needle  be  grasped  between  the  fingers  the  resistance  offered  to  it  by 
the  submucosa  is  not  so  readily  recognized.  I  am  sure  that  I  have  picked  up 


INTESTINAL  ANASTOMOSIS  215 

a  thread  of  the  submucosa  and  that  I  have  not  entered  the  lumen  of  the  in- 
testine. To  prove  that  I  have  not  entered  the  lumen  of  the  intestine  let  us 
split  the  gut  and  scrape  away  its  mucous  membrane  and  the  two  very  deli- 
cate coats — the  muscularis  mucosae  and  the  fibrosa  mucosae — which  lie 
between  this  and  the  submucosa.  You  will  observe  that  the  stitch  has  not 
perforated  the  submucosa.  Now  between  the  handles  of  the  scissors  we  will 
draw  the  submucosa.  It  is  stripped  clean  on  both  sides  and  the  cotton  thread 


Fig.  26. — Posterior  and  Lateral  Sutures  Tied. 

still  clings  to  its  surface  by  a  delicate  shred  of  this  very  tough  tissue.  For 
the  performing  of  an  intestinal  suture  of  any  kind  I  would  emphasize  the 
following  statements : 

1.  It  is  bad  surgery  to  employ  a  stitch  which  enters  the  lumen  of  the 
intestine. 

2.  It  is  impossible  to  suture  the  serosa  alone. 

3.  It  is  impossible  to  suture  unfailingly  the  serosa  and  muscularis  alone 
unless  one  is  familiar  with  the  resistance  offered  to  the  needle  by  the  coats 


216 


INTESTINAL  ANASTOMOSIS 


of  the  intestine.   Furthermore,  stitches  which  include  nothing  but  these  two 
coats  tear  out  easily  and  are,  therefore,  not  to  be  trusted. 

4.  Each  stitch  should  include  a  bit  of  the  submucosa.  A  thread  of  this 
coat  is  much  stronger  than  a  shred  of  the  entire  thickness  of  the  serosa  and 
muscularis.   It  is  not  difficult  to  familiarize  one's  self  with  the  resistance 


Fig.  27.- 


-Anterior  Row  of  Sutures  Applied  and  Drawn  Aside. 
Intestines  Not  Yet  Incised. 


furnished  by  the  submucosa,  and  it  is  quite  as  easy  to  include  a  bit  of  this 
coat  in  each  stitch  as  to  suture  the  serosa  and  the  muscularis  alone. 

5.  As  many  as  possible  of  the  stitches  should  be  taken  and  of  these  as 
many  as  convenient  should  be  tied  before  the  intestine  is  opened. 

6.  The  quilt  of  square  stitches  are  to  be  preferred  to  the  Lembert's  stitches 
because  one  row  of  them  (the  former)  is  sufficient,  and  because  they  tear 
out  less  easily  and  constrict  the  tissues  less  than  do  the  Lembert's  stitches. 
Madelung's  cartilage  plates  for  circular  suture  of  the  intestine  are  superflu- 


INTESTINAL  ANASTOMOSIS 


217 


ous  when  the  square  stitches  are  used  and  when  a  bit  of  the  submueosa  is 
taken  up  with  each  stitch. 

The  interest  in  intestinal  anastomosis  was  revived  by  Senn  a  few  years 
ago.  A  very  serious  objection  to  Semi's  operation  and  to  all  of  the  many 
modifications  of  it  is  this;  all  of  the  sutures  perforate  the  wall  of  the 
intestine. 


Fig.  28. — Intestines  Incised. 


In  operating  for  intestinal  anastomosis  we  proceed  as  follows :  six  square 
or  quilt  stitches  are  taken  in  a  straight  row  near  the  mesenteric  borders  of 
the  selected  portions  of  the  intestine  and  tied;  vid.  Figs.  24  and  25. 

At  each  end  of  this  posterior  row  of  stitches  and  nearer  the  convex  border 
of  the  intestine  two  lateral  square  stitches  are  applied  (vid.  Fig.  25)  and 
tied;  vid.  Fig.  26. 

A  little  beyond  the  convex  border  the  eight  or  nine  square  stitches  which 
constitute  the  anterior  row  and  complete  the  oval  are  applied  but  not  imme- 


218 


INTESTINAL  ANASTOMOSIS 


diately  tied.  They  are  first  drawn  aside  (vid.  Fig.  27)  to  make  room  for 
the  knife  or  scissors  with  which  the  intestines  are  then  opened ;  vid.  Fig.  28. 
Finally  the  sutures  of  the  anterior  row  are  tied  (vid.  Fig.  29)  under  a 
constant  and  gentle  irrigation  with  a  tepid  salt  solution,  6-1000,  which  is 
poured  from  the  flask  in  which  it  was  sterilized. 


Fig.  29. — Anterior  Row  of  Sutures — Four  Tied  and  Four  Not  Tied. 


Dr.  Jas.  Brown  was  kind  enough  to  note  the  time  which  one  of  the  opera- 
tions required  and  reported  it  as  8£  minutes. 

The  dogs  which  were  killed  today  were  operated  upon  three,  four  and  five 
weeks  ago.  Already  all  of  the  sutures  have  so  far  worked  their  way  out  of 
the  intestinal  walls  that  they  are  to  be  seen  shimmering  through  the  peri- 
tonaeum as  little  loops  of  black  silk.  Inasmuch  as  there  are  no  adhesions 
every  stitch  can  be  seen  distinctly.  On  cutting  open  the  specimens  we  see 
that  the  anastomosis  has  been  satisfactorily  established  in  every  case. 


INTESTINAL  ANASTOMOSIS  219 

This  operation  for  intestinal  anastomosis  has  the  following  advantages: 

1.  None  of  the  stitches  perforate  the  intestinal  wall. 

2.  All  of  the  stitches  are  applied  and  more  than  half  of  them  are  tied 
before  the  intestines  are  opened. 

3.  The  square  stitches  are  employed. 

The  Preparation  and  Preservation  of  the  Needles 

I  think  that  milliner's  needles  are  the  best  for  all  intestinal  sutures.  These 
needles  differ  from  the  ordinary  cambric  needles  only  in  that  they  are  very 
long  and  hence  easy  to  manipulate.  Nos.  8  and  9  are  good  sizes  for  the  pur- 
pose. Finer  sizes  cannot  be  threaded  easily.  Black  silk  is  to  be  preferred  to 
white  because  it  contrasts  more  strongly  with  the  parts  to  be  sewed.  In  order 
to  save  time  at  the  operation  the  needles  should  be  threaded  beforehand. 
Each  thread  should  be  about  25  cm.  long  and  should  be  tied  in  the  eye  of  its 
needle.  A  fresh  needle  and  thread  should  be  used  for  each  stitch. 

It  is  well  to  keep  a  large  stock  of  threaded  needles  constantly  on  hand. 
To  prevent  the  threads  from  becoming  entangled  we  baste  them  parallel  to 
each  other  in  small  fine  towels — about  25  threaded  needles  in  each  towel. 
A  towel  thus  armed  is  sterilized  by  steam  just  before  the  operation  and  is 
then  spread  out  in  a  solution  of  carbolic  acid,  1-40.  Each  threaded  needle 
is  withdrawn  from  the  towel  only  as  it  is  required. 


RECURRENT  VOLVULUS1 

According  to  Braun  of  Konigsberg  (Langenbeck's  Archives,  1892),  de- 
torsion  has  been  accomplished  in  seventeen  cases  of  volvulus  of  the  sigmoid 
flexure.  Six,  or  about  35  per  cent,  of  these  cases  recovered.  Of  the  11  fatal 
cases,  2  died  of  collapse  soon  after  the  operation,  5  of  peritonitis  or  gangrene 
of  the  intestine,  1  of  pneumonia,  1  of  a  recurrence  of  the  volvulus,  1  of 
typhoid  fever,  and  1  probably  of  tuberculous  meningitis. 

In  two  instances  the  volvulus  recurred;  in  one,  immediately  after  the 
operation,  and  in  the  other,  four  months  after  the  operation.  Both  of  these 
cases  died ;  one  without  a  second  operation,  and  the  other  on  the  third  day 
after  the  operation,  presumably  of  typhoid  fever. 

Dr.  Finney's  case  is,  therefore,  the  second  in  which  detorsion  for  recur- 
rent volvulus  of  the  sigmoid  flexure  has  been  accomplished,  and  the  first  in 
which  it  has  been  successfully  accomplished. 

Four  patients,  for  whom  detorsion  was  not  performed  because  the  volvulus 
was  not  discovered  at  the  time  of  the  operation,  died  soon  after  the  operation. 
Resection  of  the  intestine  for  volvulus  of  the  sigmoid  flexure  has  been  done 
in  two  instances.  One  of  the  patients  died  on  the  thirty-second  day  from 
perforations  of  an  ulcer  of  the  stomach;  the  other  recovered  from  the 
operation  with,  however,  a  faecal  fistula. 

All  of  the  eight  cases  upon  whom  enterotomy  was  performed  died  within 
a  very  short  time. 

It  is  clear  from  these  statistics  that  for  volvulus  of  the  sigmoid  flexure 
detorsion  should  be  performed  as  soon  as  possible.  The  proposition  of  Treves, 
to  puncture  the  intestine  and  then  perform  colotomy  on  the  descending 
colon,  should,  as  Braun  says,  not  for  a  moment  be  considered.  To  prevent 
a  recurrence  of  the  volvulus  it  has  been  proposed  by  Senn  to  shorten  the 
mesocolon.  Senn  has  accepted  the  popular  notion  that  a  long  mesocolon  is 
the  predisposing  cause  of  volvulus  of  the  sigmoid  flexure.  This  notion  has 
not,  however,  the  support  of  facts.  In  almost  all  of  these  cases  a  short,  thick 
mesocolon  has  been  found.  Gruber  has  found  the  mesocolon  as  short  as 
1  inch  and  not  longer  than  1\  inches  in  the  cases  which  he  has  examined 
post  mortem.  Kuttner  has  seen  both  arms  of  the  sigmoid  flexure  lying  close 
together. 

1  Remarks  in  discussion  of  Dr.  J.  M.  T.  Finney's  paper,  "  Recurrent  volvulus."  The 
Johns  Hopkins  Hospital  Medical  Society.  Baltimore,  January  16,  1893. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1893,  iv,  28. 
220 


RECURRENT  VOLVULUS  221 

If  one  should  attempt  to  shorten  the  mesocolon  in  such  cases  he  "would, 
as  Braun  says,  produce  a  sharp  bend  of  the  intestine.  He  might,  further- 
more, shut  off  the  circulation  to  a  disastrous  extent. 

In  our  case  the  mesentery  seemed  quite  as  long  if  not  longer  than  the 
normal  mesosigmoideum.  May  it  not  after  all  be  possible  that  a  long 
mesentery  is  often  the  predisposing  cause  of  the  volvulus,  and  that  an 
originally  long  mesentery  may,  by  adhesions  and  other  processes  of  peri- 
tonitis, become  a  short  and  thick  one  ? 

There  is  a  physiological  volvulus  of  the  sigmoid  flexure.  A  torsion  of  as 
much  as  180°  has  several  times  been  observed. 

There  is  also  a  physiological  volvulus  of  the  large  intestine  upon  the  small 
intestine.  The  entire  navel  loop  is  concerned  in  this  volvulus.  It  occurs  in 
the  embryo  when  the  flexura  linealis  crosses  the  rlexura  duodeno-jejunalis. 
It  is  probably  this  twist  which  causes  the  fold  known  as  the  plica  duodeno- 
jejunalis,  and  the  fossa  known  as  Treitz's  fossa  or  the  recessus  duodeno- 
jejunalis  or  recessus  retroperitonaealis.  It  is  a  subject  for  investigation 
whether  the  ligamentum  mesenterio-mesocoelicum  owes  its  occasional  exis- 
tence to  a  physiological  volvulus  of  the  sigmoid  flexure. 


A  DIAGNOSTIC  SIGN  IN  APPENDICITIS1 

Male,  aet.  30.  I  exhibit  this  case  not  for  any  particularly  interesting 
feature  of  its  own,  but  because  I  wish  to  call  your  attention  to  a  diagnostic 
sign  of  appendicitis  which  I  believe  to  be  of  considerable  importance.  My 
experience  would  teach  me  that  this  particular  sign  is  probably  present  in 
all  cases,  and  in  all  stages,  except  one,  of  the  disease.2  It  is  this :  One  can- 
not press  with  the  fingers  into  the  false  pelvis  on  the  affected  side  so  deeply 
as  on  the  healthy  side.  In  the  earliest  stages  it  is  a  spasm  of  the  muscles 
which  prevents  one  from  dipping  into  the  iliac  fossa.  Later  it  is  the  ad- 
hesions between  the  caecum  and  the  abdominal  paries,  and  occasionally  be- 
tween the  omentum  and  abdominal  paries.  And,  finally,  it  is  the  exudate 
itself.  At  times  two,  and  at  times  all  three,  of  these  obstructing  factors  may 
be  present.  It  is  the  exception  that  one  of  them  is  found  alone.  It  is  only 
to  the  first,  and  afterward  to  the  second,  of  these  factors  that  I  particularly 
wish  to  call  your  attention.  The  muscle-spasm  may  be  so  great  and  its  edges 
so  sharply  defined  that  inspection  reveals  a  fullness,  and  palpation  detects 
what  seems  to  be  an  induration.  This  muscle-spasm  may  be  partially  or 
wholly  eliminated  by  the  proper  application  of  the  Paquelin  cautery.  When 
the  patient  is  fully  anaesthetized  no  trace  of  the  spasm  remains.  We  have 
seen  some  cases  so  early  that  nothing  but  the  spasm  of  the  muscle  has  pre- 
vented us  from  dipping  normally  into  the  iliac  fossa.  More  frequently, 
however,  in  addition  to  the  muscle-spasm  there  have  been  adhesions  between 
the  caecum  and  the  parietal  peritonaeum.  It  is  possible  to  foretell  the  pres- 
ence of  these  adhesions,  in  the  absence  of  any  considerable  exudate  (of  any- 
thing more  than  a  few  drops  of  pus),  by  palpation  of  the  brim  of  the  pelvis 
and  of  the  iliac  fossa.  In  this  patient  the  adhesions  between  the  parietal 
omentum  and  parietal  peritonaeum  prevented  us  from  dipping  normally  into 
the  pelvis  on  the  right  side.  After  separating  these  adhesions  we  at  once 
encountered  the  erect  central  half  of  the  appendix  in  cross  section.  The 
appendix  had  been  bent  upon  itself  at  a  right  angle  or  less,  and  had  ulcerated 
through  at  about  its  middle.   The  peripheral  piece  was  adherent  to  the  ab- 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  December 
18,  1893. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1894,  v,  32. 

2  When  the  patient  has  general  peritonitis  and  the  abdomen  is  excessively  tympanitic 
the  sign  to  which  I  refer  may  be  masked. 

222 


A  DIAGNOSTIC  SIGN  IX  APPENDICITIS  223 

dominal  wall.  There  was  a  little  pus,  three  or  four  drops  at  most,  encap- 
sulated between  the  abdominal  paries  and  the  peripheral  end  of  the  central 
piece  and  the  central  end  of  the  peripheral  piece  of  the  appendix.  A  point 
of  great  importance  in  the  operative  treatment  of  these  cases,  and  one  to 
which  we  give  perhaps  an  unusual  amount  of  attention,  is  the  packing  off 
of  the  uninfected  portion  of  the  abdominal  cavity  from  the  infected  portion 
prior  to  opening  the  abscess,  however  small  this  abscess  may  be.  And  even 
when  we  believe  that  there  is  no  abscess  we  pack  off  the  general  cavity  with 
just  as  much  care  prior  to  the  separation  of  the  adhesions  which  glue  the 
caecum  to  the  parietal  peritonaeum ;  and,  in  the  absence  of  such  adhesions, 
prior  to  separating  the  adhesions  which  bind  down  the  appendix.  Should 
pus  be  present,  it  is  carefully  caught  and  disposed  of  in  such  a  way  that 
there  is  perhaps  the  least  possible  danger  of  infecting  the  general  peritonaeal 
cavity.  I  fear  that  I  cannot  well  describe  to  you  our  method  of  packing  off 
and  protecting  the  general  peritonaeal  cavity.  We  use  a  good  many  sponges 
of  gauze  superimposed  upon  each  other  in  such  a  way  that  should  the  inner- 
most ones  become  soiled  the  outermost  remain  clean.  It  is  well,  if  possible, 
to  so  pack  the  outermost  strips  of  gauze  that  they  may  remain  undisturbed 
and  form  a  part  of  the  final  packing  of  the  wound.  For  adhesions  form 
with  surprising  rapidity  (in  a  few  minutes)  which  it  is  undesirable  to  dis- 
turb. We  have  operated  upon  thirty-four  cases  of  appendicitis,  and  without 
a  death  if  we  except  the  nine  perfectly  hopeless  cases  which  had  acute  sup- 
purative peritonitis  before  they  were  operated  upon.  Five  cases  of  appendi- 
citis with  a  less  desperate  form  of  peritonitis  were  saved  by  operation. 

Of  four  cases  of  appendicitis  without  peritonitis  operated  upon  by  me 
outside  of  the  hospital,  all  recovered  from  the  disease;  and  of  two  with 
general  suppurative  peritonitis,  both  recovered  from  the  peritonitis,  but 
one  of  them  died  from  haemorrhage  about  two  weeks  after  the  operation  and 
when  he  was  believed  to  be  surely  convalescent. 


A  POSTSCRIPT  TO  THE  REPORT  ON  APPENDICITIS1 

Dr.  Einney's  remarks  on  the  treatment  of  the  wound  in  cases  of  appen- 
dicitis have  been  abbreviated  so  much,  as  possibly  to  mislead  those  who  are 
not  familiar  with  our  methods.  When  he  speaks  of  "  leaving  the  abdominal 
wound  open  "  he  means  that  the  wound  is  drained  with  gauze,  and  not  that 
no  attempt  is  made  to  close  it.  The  fact  is  that  the  wound  is  sewed  up  tight 
about  the  gauze,  so  tight  that  it  is  sometimes  necessary  to  cut  one  stitch  in 
order  to  remove  the  packing.  Whenever  pus  is  encountered  either  within 
the  appendix  or  outside  of  it  the  wound  is  drained.  Sometimes  one  or  two 
narrow  strips  of  gauze  are  sufficient,  sometimes  very  many  broad  strips  are 
required.  Ordinarily  all  of  the  gauze  is  brought  out  at  one  point  and  between 
stitches  which,  as  I  have  said,  embrace  it  snugly.  The  gauze  is  used  not  only 
for  drainage,  but  quite  as  much  to  stimulate  adhesions  between  the  coils  of 
intestine  which  surround  it  and  thus  effectually  shut  off  the  general  peri- 
tonaeal  cavity  from  its  infected  portion.  The  gauze  is  gently  packed  about 
the  stump  of  the  appendix,  and  should  reach  into  every  recess  of  the  pus 
cavity.  When  the  abscess  is  a  large  and  ramifying  one,  or  when  there  are 
several  abscesses,  we  may  bring  the  gauze  packing  out  of  the  abdomen  at 
more  than  one  point  in  the  wound. 

These  wounds  are  closed  with  mattress  sutures;  but  the  sutures  are  not 
always  buried  as  they  are  in  all  uninfected  abdominal  wounds  which  are 
completely  closed  and  in  which  the  danger  of  stitch  infection  is  not  so  great. 
The  stitches,  where  they  are  not  buried,  are  prevented  from  cutting  into 
the  skin  by  pieces  of  rubber  tubing  or  of  gauze.  These  wounds  should  be 
stitched  with  great  care.  All  of  the  divided  tissues  (the  peritonaeum  ex- 
cepted) should  be  included  in  each  stitch  unless  the  stitches  are  buried. 
Inasmuch  as  the  muscles  retract  unevenly  the  sewing  is  sometimes  a  diffi- 
cult task.  If  the  wound  is  sewed  in  this  way,  and  if  sufficient  care  is  exer- 
cised to  avoid  the  infection  of  the  stitches  as  they  are  being  introduced  and 
tied,  there  is  little  if  any  danger  that  a  hernia  will  ensue/ 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  April  2, 1894. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1894,  v,  113-114. 

2  At  the  meeting  of  The  Johns  Hopkins  Hospital  Medical  Society,  November  5, 
1894,  I  presented  a  case  of  appendicitis  to  illustrate  our  treatment  of  the  incision. 
Buried  sutures  of  .silver  wire  had  been  used  to  bring  together  the  cut  edges  of  the 
abdominal  muscles,  and  an  uninterrupted  buried  .suture  of  silver  wire  closed  the 
wound  in  the  skin.  The  latter  suture  had  already  been  withdraws  and  a  tine  pink 
line  indicated  where  the  skin  incision  had  been  made.  A  little  below  the  centre  of 
the  wound  was  the  orifice  of  a  sinus  from  which  a  narrow  strip  of  gauze  had  just 
been  removed.  The  cicatrix  was  three  weeks  old. 

224 


APPENDICITIS  235 

Even  the  point  at  which  the  gauze  traverses  the  abdominal  wall  is  not  a 
weak  one.  A  connective  tissue  membrane,  the  wall  of  the  obliterated  sinus, 
extends  from  the  stump  of  the  appendix  to  this  point  in  the  wound  and 
binds  the  intestines  to  each  other  and  to  the  underside  of  the  lips  of  the  open 
part  of  the  wound.  The  thickness  of  this  membrane  depends  principally 
upon  the  length  of  time  the  gauze  is  allowed  to  remain  undisturbed.  I  have 
found  it  so  strong  after  ten  days  that  I  could  with  difficulty  thrust  my  finger 
through  it.  This  membrane  atrophies  in  time.  After  two  years  I  have  found 
the  walls  of  a  sinus  to  the  gall  bladder  attenuated  to  little  more  than  a  trace. 

With  our  present  resources  it  is  not  justifiable  to  attempt  to  disinfect  an 
abscess  cavity  of  the  peritonaeum,  no  matter  how  infinitesimally  small  this 
abscess  may  be.  Bull  and  two  others,  whose  names  I  am  not  at  liberty  to 
mention,  are  probably  not  the  only  ones  who  have  furnished  disastrous  in- 
stances of  such  attempts. 

In  operations  for  appendicitis  we  have  always  the  strangulated  stump  of 
the  appendix  and  usually  tissues  more  or  less  necrotic  in  its  immediate 
vicinity  as  a  complication.  My  experiments  3  demonstrated  conclusively  the 
result  of  inoculation  of  strangulated  tissues  in  the  peritonaeal  cavity. 

The  problem  is  a  very  different  one  when  we  have  an  abscess  in  the  can- 
cellous tissue  of  bone  or  in  highly  vascular  soft  parts  to  deal  with.  We  may 
safely  close  such  abscess  cavities.  If,  for  example,  the  so-called  pyogenic  wall 
of  an  abscess  in  muscle  is  excised  and  the  parts  are  then  thoroughly  washed 
with  an  antiseptic  solution,  we  may  so  far  inhibit  the  pyogenic  organisms 
that  the  tissues  or,  if  there  is  a  dead  space,  the  prolific  granulations,  assisted 
possibly  by  the  blood,  may  altogether  destroy  them.  In  the  cancellous  tissue 
of  bone  a  cavity  large  enough  to  hold  a  hickory  nut  becomes  completely  filled 
with  granulations  in  about  three  days.  Blood  clots  occupying  such  cavities, 
if  inoculated  with  virulent  cultures  of  Staphylococcus  aureus,  rarely  break 
down.  As  a  rule,  the  socalled  organization  of  the  clot  takes  place  in  from 
two  to  four  days  without  suppuration.  But  an  abscess  in  the  peritonaeal 
cavity  is  a  very  different  affair  because  ( 1 )  the  wall  of  the  abscess  consists  in 
part  of  strangulated  or  more  or  less  necrotic  tissue  which  we  cannot  excise ; 
(2)  attempts  to  disinfect  such  an  abscess  would  probably  be  futile  and  might 
be  worse  than  futile;  (3)  failure  to  disinfect  might  mean  general  peritonitis 
and  the  death  of  the  patient,  and  not  merely  the  retardation  of  healing. 

There  cannot  be  a  definite  incision  for  appendicitis.  In  general,  if  there 
is  a  large  abscess,  the  incision  should  be  made  as  near  as  possible  to  the 
crest  of  the  ileum,  so  as  to  diminish  the  chances  of  entering  the  clean  peri- 
tonaeal cavity  and  to  lessen  the  possibility  of  a  hernia.  The  muscles  are  thick 
in  this  region,  and  when  divided  offer  broad  surfaces  for  coaptation  by 

3  The  Johns  Hopkins  Hospital  Reports.   Report  in  Surgery,  I. 
16 


226  APPENDICITIS 

suture ;  and  if  the  incision  is  too  close  to  the  ileum  to  admit  of  suture  there 
is  little  danger  of  hernia  resulting,  as  we  know  from  a  long  experience  with 
psoas  abscesses,  which  we  open  by  preference  in  this  region.  But  the  position 
of  the  abscess  or,  if  there  is  no  pus  or  too  little  pus  to  be  detected,  the  posi- 
tion of  the  appendix  in  the  given  case  should  determine  the  site  of  the 
incision.  If  there  is  an  abscess  the  tissues  over  it  should  be  most  carefully 
studied  as  they  are  being  incised  for  signs  of  infiltration  with  inflammatory 
products.  A  little  oedema  of  the  deeper  muscles  (transversalis  or  internal 
oblique)  may  guide  us  to  a  circumscribed  spot  of  adhesion  of  caecum  or 
omentum  to  parietal  peritonaeum  and  enable  us  to  empty  a  large  abscess 
without  entering  the  uninfected  part  of  the  peritonaeal  cavity,  or  to  thor- 
oughly protect  the  intestines  about  the  encapsulated  pus  cavity  from  the 
danger  of  infection  before  the  pus  is  liberated.  We  place  several  yards  of 
gauze  between  the  healthy  intestines  and  the  abscess  before  opening  the 
latter. 

From  a  bacteriological  point  of  view,  we  must  often,  if  not  always,  inocu- 
late the  healthy  peritonaeum,  but  thus  far  we  have  not  in  a  single  instance 
had  peritonitis  supervene  upon  an  operation  for  appendicitis,  nor  have  we 
a  single  death  to  attribute  to  the  operation.  In  the  case  of  a  large  abscess, 
which  we  have  evacuated  without  entering  the  uninfected  peritonaeal  cavity, 
we  still  hesitate  to  search  for  and  remove  the  appendix  if  its  removal  would 
necessitate  our  entering  the  clean  peritonaeal  cavity. 

When  there  is  little  or  no  pus  to  be  discovered  we  make  our  incision 
directly  over  the  appendix,  which  can  usually  be  palpated.  Here,  too,  we 
try  to  cut  through  thick  muscles  if  possible.  The  instant  that  the  peritonaeum 
is  opened,  and  before  it  is  widely  incised,  we  introduce  large  towels  of  gauze, 
and  with  these  press  the  intestines  over  the  appendix  out  of  the  way  and 
towards  the  left.  When  the  appendix  is  nicely  exposed  and  a  clear  field  for 
operation  obtained,  we  introduce  more  gauze  to  serve  as  an  inner  lining  to 
the  outer  ring  of  gauze.  The  adhesions  which  bind  down  the  appendix  are 
then  slowly  broken  up  by  gentle  finger  pressure,  and  if  pus  is  present  it  is 
caught  as  it  leaks  out  by  additional  gauze  sponges.  If  the  inner  layer  of 
gauze  packing  should  by  accident  become  soiled  it  is  immediately  replaced 
by  fresh  packing,  the  opening  into  the  abscess  being  meanwhile  stopped  with 
a  gauze  sponge.  And  so,  little  by  little,  the  abscess  is  emptied,  and  finally 
the  appendix  removed.  After  ligating  the  appendix  and  its  mesentery  we 
may  excise  the  mucosa  which  is  cut  off  by  the  ligature.  We  never  sew  up 
the  end  of  the  stump  in  the  infected  cases,  as  some  surgeons  have  advised. 
This  would  be  a  foolish  waste  of  time,  for  the  circulation  of  the  part  stitched 
has  been  cut  off  by  the  ligature  applied  to  the  appendix.  The  gauze  for  pack- 
ing is  rubbed  full  of  a  mixture  of  iodoform  and  bismuth  and  then  sterilized. 


INFLATED  RUBBER  CYLINDERS  FOR  CIRCULAR  SUTURE 
OF  THE  INTESTINE1 

Until  ten  years  ago  every  one  who  had  written  on  the  subject  of  intestinal 
suture  believed  that  the  Lembert  stitches,  which  were  then  almost  uni- 
versally used  in  circular  and  other  sutures  of  the  intestine,  included  only 
the  peritonaeal  coat  of  the  intestine ;  and  many  surgeons  evidently  still  be- 
lieve this.  The  notions  of  Jobert  and  Lembert  as  to  the  structure  of  the 
intestinal  wall  were  still  accepted  by  all  surgeons.  The  submucous  coat  of 
the  intestine,  the  coat  which,  I  am  convinced,  should  most  concern  the  sur* 
geon  when  he  is  sewing  the  intestine,  was  ignored  or  unknown.  In  my  first 
article  on  suture  of  the  intestine2  in  1887  I  quoted  from  Madelung3  as 
follows :  "  The  needle  now  penetrates  in  the  usual  manner  the  two  ends 
of  the  intestine,  passing  between  serosa  and  muscularis  " ;  and  from  Reichel," 
who  insists  upon  the  "  accurate  adaptation  of  the  two  edges  of  the  wound, 
particularly  of  the  two  serous  coats,"  and  having  described  the  manner  of 
taking  the  first  row  of  stitches,  continues,  "  over  this  then  comes  the  ex- 
ternal suture,  which  includes  only  the  serosa."  Maydl,  Kocher,  Czerny  and 
others  were  quoted  to  show  that  the  submucous  coat  had  not  been  recognized, 
and  how  universal  was  the  opinion  that  intestinal  suture  should  be  per- 
formed by  stitches  which  included  only  the  peritonaeal  coat.  When  we  know 
that  the  wall  of  the  intestine  must  be  magnified  to  a  thickness  of  4  cm.  to 
enable  us  to  represent  the  peritonaeal  coat  by  a  fine  pencil-stroke,  we  find  it 
hard  to  understand  that  surgeons  should  ever  have  supposed  that  they  were 
including  nothing  but  peritonaeum  in  their  stitches.  Hardly  less  remarkable 
is  the  fact  that  the  intestinal  wall  had,  for  the  surgeon,  only  three  coats — 
the  serous,  muscular,  and  mucous  coats.  Not  only  were  the  qualities  of 
the  submucosa  unknown  to  surgeons,  it  was  also  an  unknown  quantity. 
Only  five  years  ago  Schimmelbusch,5  describing  with  some  detail  the  manu- 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  December 
13,  1897. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1898,  ix,  25-27. 

Also:   Phila.  M.  J.,  1898,  i,  63-68.   (Reprinted.) 

2Halsted:  Circular  Suture  of  the  Intestine.  An  Experimental  Study.  Am.  Jour. 
Med.  Sciences,  October,  1887. 

3  Madelung:   Arch.  f.  klin.  Chirurgie,  Bd.  xxvii,  p.  321. 

4Reichel:    Deutsche  Zeitschr.  f.  Chirurgie,  Bd.  xiv,  pp.  268  and  270. 

5  Schimmelbusch :    Anleitung  zur  aseptischen  Wundbehandlung,  Berlin,  1892,  p.  104. 

227 


228  INFLATED  RUBBER  CYLINDERS 

facture  of  the  so-called  catgut,  tells  us  that  it  is  made  from  the  longitudinal 
muscular  coat.  He  says,  "  If  the  intestine  be  laid  on  a  towel  and  scraped 
with  a  dull  instrument  like  the  back  of  a  knife,  the  muck  ('  Schmutz '),  so 
called  by  the  artisans,  is  removed.  This  is  nothing  else  than  the  mucous 
membrane  of  the  gut.  In  the  same  manner  the  circular  muscular  coat  is 
rubbed  off,  so  that  only  the  very  thin  tube  composed  of  longitudinal  muscle- 
fibres  remains,  an  intact,  very  delicate  and  pipe-like  structure  which  may 
be  distended  with  air.  The  threads  are  manufactured  from  this  by  twisting, 
and  conformably  to  the  thickness  desired,  either  the  entire  tube  or  only 
strips  of  it  are  twisted  together  like  hempen  cords."  The  muscular  pipe 
referred  to  is,  of  course,  the  tube  of  the  submucosa,  the  sausage-skin,  etc. 

The  following  suggestions,  emphasized  among  others,  in  my  article  on 
intestinal  anastomosis,8  are  equally  relevant  to  circular  suture  of  the 
intestine : 

"1.  It  is  bad  surgery  to  employ  stitches  which  enter  the  lumen  of  the 
intestine. 

"2.  It  is  impossible  to  suture  the  serosa  alone. 

"  3.  It  is  impossible  to  suture  unfailingly  the  serosa  and  muscularis  alone, 
unless  one  is  familiar  with  the  resistance  offered  to  the  needle  by  the  sub- 
mucous coat  of  the  intestine;  furthermore,  stitches  which  include  nothing 
but  the  serous  and  muscular  coats  tear  out  easily  and  are  not  to  be  trusted. 

"  4.  Each  stitch  should  include  a  bit  of  the  submucosa.  A  fine  thread  of 
this  coat  is  much  stronger  than  a  considerable  shred  of  the  entire  thickness 
of  the  serosa  and  muscularis.  It  is  not  difficult  to  familiarize  one's  self  with 
the  resistance  offered  to  the  needle  by  the  submucosa,  and  with  a  very  little 
practice  one  learns  to  include  a  bit  of  this  coat  in  each  stitch. 

"  5.  The  mattress-stitches  are  to  be  preferred  to  Lembert's,  because  one 
row  of  them  is  sufficient,  because  they  tear  out  less  easily,  oppose  larger 
surfaces  and  more  evenly,  and  constrict  the  tissues  less  than  the  Lembert 
stitches  do." 

6.  In  circular  suture  of  the  intestine,  only  one  row  of  stitches  should  be 
taken,  and  the  entire  row  should  be  applied  before  a  single  stitch  is  tied; 
otherwise  it  is  impossible  to  preserve  a  straight  line  in  the  taking  of  the 
stitches,  and  the  stitches  taken  last  may  be  never  so  much  farther  from  the 
cut  edge  than  those  taken  first,  and  the  flange  turned  in  may  be  so  broad  as 
to  occlude  the  intestine's  lumen. 

7.  Before  the  intestine  is  resected,  its  blood-supply  should  be  most  care- 
fully studied,  with  reference  not  only  to  the  placing  of  ligatures,  but  also  of 

0  Halstcd :  Intestinal  Anastomosis.  Demonstration  at  a  meeting  of  The  Johns 
Hopkins  Hospital  Medical  Society,  December  1,  1890.  Johns  Hopkins  Hospital  Bulle- 
tin, January,  1891. 


CIECULAK  SUTUEE  OF  IXTESTINE  229 

the  stitches,  and  the  stitches  should  be  so  placed  that  the  circulation,  up 
to  the  very  edge  of  the  parts  to  be  sewed,  shall  be  as  perfect  as  possible. 

The  results  obtained  by  adhering  strictly  to  the  foregoing  rules  have  been 
so  perfect 7  that  we  have  employed  no  other  methods  in  our  practice. 

Edmunds  and  Ballance  in  their  valuable  contribution 8  to  intestinal  sur- 
gery, give  the  results  of  their  measurements  to  determine  the  relative  thick- 
ness of  the  submucous  and  muscular  coats  in  the  dog  and  in  man.  They 
state  that  the  muscular  coat  is  very  much  thicker  in  the  dog  than  in  man, 
but  that  the  submucous  coat  is  somewhat  thicker  in  man  than  in  the  dog, 
and  they  too  find  it  perfectly  feasible  to  engage  a  thread  of  the  submucosa 
in  each  stitch  without  perforating  the  lumen  of  the  intestine. 

The  objection  to  Xeuber's  °  decalcified  bone-bobbins,  Senn's  decalcified 
bone-plates,  and  Murphy's  button,  probably  the  best  of  the  mechanical  aids 
to  intestinal  suture,  I  will  not  dwell  upon  at  this  time.  The  method  of  each 
of  these  surgeons  has  its  advantages,  particularly  in  the  hands  of  those  who 
have  not  practised  the  intestinal  sutures  on  animals. 

I  believe  that  the  license  to  practise  general  surgery  should  be  withheld 
from  those  who  have  not  practised  on  animals  the  operations  for  circular 
suture  of  the  intestine  and  intestinal  anastomosis. 

Not  so  very  long  ago  a  surgeon  requested  me  to  assist  him  to  perform  a 
circular  suture  of  the  intestine  (end  to  end  anastomosis)  upon  one  of  his 
patients.  He  readily  consented  to  practise  the  operation  upon  dogs.  At  first 
his  dogs  died.  He  finally  succeeded  in  saving  more  than  50  per  cent  of  the 
dogs  operated  upon.  The  operation  upon  his  patient  required  five  hours, 
but  was  successful.  It  is  not  difficult  to  predict  what  the  result  would  have 
been  if  the  practice  on  dogs  had  been  omitted. 

Experts  in  intestinal  surgery,  almost  without  exception,  prefer  to  per- 
form circular  suture  of  the  intestine  without  the  use  of  mechanical  devices. 

1  Amer.  Jour.  Med.  Sciences,  October,  1887. 

8  W.  Edmunds  and  Charles  A.  Ballance:  Observations  and  Experiments  on  Intestinal 
and  Gastro-intestinal  Anastomosis.    Medico-Chirurg.    Trans.,  Vol.  78,  London,  1896. 

9  A  few  weeks  ago  Dr.  Mitchell  discovered  in  the  Medical  and  Surgical  Reporter 
for  July,  1896,  a  description  by  Dr.  A.  J.  Downes,  of  collapsible  rubber  bobbins  for  all 
forms  of  intestinal  approximation.  These  bobbins  resemble  Neuber's  bobbins  very 
closely  and  were  designed  with  the  same  end  in  view,  viz.,  to  accommodate  the 
inverted  ends  in  circular  suture  of  the  intestine.  My  rubber  cylinders  were  made  in 
June,  1897,  and  were  suggested  to  me  by  the  success  attending  the  employment,  experi- 
mentally, of  aluminum  rods  in  suture  of  the  common  bile-duct.  I  intend  to  describe 
these  rods  at  another  time.  Dr.  Downes'  bobbins  have  spherical  ends,  which  are  filled 
with  water.  When  a  larger  is  to  be  sutured,  end  to  end,  to  a  smaller  intestine  he  uses 
a  bobbin  especially  designed  for  the  purpose,  with  a  large  sphere  at  one  end  and  a 
small  sphere  at  the  other  end  of  the  connecting  shank.  I  should  suppose  that  this 
modification  of  the  bobbin  would  defeat  the  very  end  for  which  it  was  constructed. 


230  INFLATED  EUBBEE  CYLINDERS 

But  my  operation  was  not  by  any  means  a  satisfactory  one,  notwithstand- 
ing the  very  perfect  results  which  attended  its  employment  in  the  hands  of 
others  as  well  as  myself. 

The  disadvantages  of  my  original  method  and  of  all  similar  methods 
(methods  without  mechanical  aids)  were  as  follows: 

1.  They  required  about  twenty  minutes  to  perform  the  operation. 

2.  One  or  two  assistants  at  the  wound  were  indispensable. 

3.  Clamps  or  the  fingers  of  an  additional  assistant  were  necessary  to  pre- 
vent the  escape  of  intestinal  contents. 

4.  The  vermicular  action  of  the  intestine  (particularly  in  dogs)  was  a 
great  annoyance,  for  it  prevented  an  accurate  disposition  of  the  stitches; 
stitches  applied  as  near  together  as  possible  during  intestinal  contraction 
might  be  too  far  apart  in  the  stage  of  relaxation. 

5.  If  the  pieces  of  intestine  to  be  united  were  not  of  the  same  size  their 
adjustment  might  be  very  difficult. 

6.  The  rolling  out  of  the  cut  edges  of  the  intestine  prevented  in  places 
recognition  of  the  precise  edges,  and  hence  the  operator  might  not  know 
just  how  far  from  the  edge  he  was  placing  his  stitches  nor  just  how  much 
intestine  he  was  turning  in. 

7.  The  handling  of  the  intestine  by  assistants  who  act  as  clamps  or  who 
holds  parts  in  place  during  the  stitching  must  be  injurious  to  the  tissues 
and  predispose  to  infection. 

Every  one  of  these  objections  is  disposed  of  by  the  employment  of  the 
rubber  cylinders  in  the  manner  indicated  in  the  plates.  The  drawings  are 
so  excellent  and  illustrate  the  method  so  graphically  and  accurately  that  a 
description  of  the  procedure  is  almost  superfluous. 

Plate  IX  and  Plate  X,  1,  show  the  presection-stitches  applied.  It  is 
immaterial  whether  these  stitches  perforate  the  wall  of  the  intestine  or  not, 
for  they  are  cast  off  eventually  into  the  bowel.  The  method  of  ligating  the 
mesenteric  vessels  is  also  accurately  shown  in  Plate  IX  and  Plate  X,  1,  which 
were  drawn  from  life.  The  intestine  should  be  divided  carefully  with  scis- 
sors as  close  to  the  presection-stitches  as  possible.  Xo  visible  blood-vessels 
are  occluded  by  these  stitches. 

Plate  X,  2.  The  rubber  cylinder  inflated.  For  the  human  small  intestine 
the  diameter  of  the  cylinder  is  from  1}  to  1£  inches.  It  would  be  better  to 
have  cylinders  larger  than  necessary  rather  than  too  small. 

In  Plate  XI  two  of  the  presection-stitches  have  been  tied,  and  the  col- 
lapsed rubber  cylinder  is  being  pushed  into  the  bowel  with  a  forceps. 

Plate  XII.  The  three  presection-stitches  have  been  tied.  They  are  sup- 
plemented by  a  fourth  stitch,  b,  which  ifl  removed  later  to  facilitate  the  with- 
drawal of  the  bag.  The  bag  has  been  inflated  with  air  by  the  syringe.  Water 


CIKCULAK  SUTURE  OF  INTESTINE  231 

might,  of  course,  be  used  instead  of  air ;  but  a  bag  distended  with  air  would, 
perhaps,  more  quickly  reveal  a  prick  from  a  faulty  stitch  than  a  bag  dis- 
tended with  water. 

The  stitch  a  (Plate  XIII,  1,  and  also  Plate  XII,  Plate  XIII,  2,  and  Plate 
XIV,  1)  is  the  first  and  most  important  of  the  mattress  or  permanent 
stitches.  The  submucosa  is  picked  up  four  times  by  this  as  by  all  the  mat- 
tress stitches,  and  the  mesentery  is  twice  perforated  by  it  (Plate  XIII,  1). 
This  stitch  insures  the  proper  turning  in  of  the  mesenteric  border.  It  was 
devised  by  Drs.  Mitchell  and  Hunner,  and  I  shall  call  it  the  Mitchell-Hunner 
stitch. 

Plate  XIII,  2.  The  bag  is  still  distended,  and  all  of  the  mattress  stitches 
have  been  placed.  From  seven  to  nine  of  these  stitches  suffice  in  operations 
upon  the  small  intestine  of  the  dog,  and  from  ten  to  twelve  in  operations 
upon  the  human  subject.  The  first  stitch  to  be  drawn  home  and  tied  is  a. 
The  mesenteric  border  is  turned  in  by  it  infallibly.  Not  a  single  visible  ves- 
sel is  occluded  by  the  stitches  (Plate  XIII,  2,  and  Plate  XIV,  1).  On  the 
right  side  the  stitches  pass  under  one  vessel  and  over  another,  without  inter- 
fering with  either,  and  on  the  left  side  a  vessel  lies  under  the  stitches, 
uninjured. 

Plate  XIV,  1.  Two  mattress  stitches  drawn  aside  on  a  hook;  the  tem- 
porary stitch  has  been  removed  and  the  collapsed  bag  is  being  withdrawn. 

Plate  XIV,  2.  The  circular  suture  is  completed ;  the  slit  in  the  mesentery 
is  being  sewed  in  such  a  way  that  its  circulation  is  not  interfered  with. 

Advantages  of  the  Inflated  Rubber  Cylindek  in  Circular  Suture 
of  the  Intestine 

1.  The  vermicular  action  of  the  bowel  is  arrested  over  the  bag,  and  the 
stitches  can,  consequently,  be  placed  at  regular  and  proper  intervals. 

2.  The  distended  bag  unrolls  and  spreads  out  to  a  fine  edge  the  everted 
raw  edge  of  the  intestine  (Plate  XI),  and  enables  the  operator  to  place  the 
stitches  with  great  precision  at  the  desired  distance  from  this  edge. 

3.  If  distended  intestine  is  to  be  sutured  to  collapsed  intestine  (in  stran- 
gulated hernia,  ilius,  etc.),  or  intestine  of  larger  to  intestine  of  smaller 
lumen  (jejunum  to  ileum,  duodenum  to  esophageal  end  of  the  stomach, 
etc.),  the  smaller  may  easily  be  expanded  to  fit  the  larger  piece.10 

"I  have  recently  had  occasion  to  unite  a  distended  paper-thin  jejunum  to  a  col- 
lapsed ileum.  The  rubber  cylinder  worked  like  a  charm.  The  patient,  a  very  old  and 
feeble  woman,  convalesced  without  interruption  for  16  days.  She  died  quite  suddenly 
from  peritonitis  due  to  complications  which  cannot  at  this  time  be  discussed.  So  far 
as  the  stitching  was  concerned  the  result  was  perfectly  satisfactory. 


232  INFLATED  RUBBER  CYLINDERS 

4.  Very  little  handling  of  the  intestine  itself  by  the  operator  is  necessary. 
The  tube  from  bag  to  syringe  is  used  as  a  handle  to  rotate  and  elevate  the 
parts  to  be  united. 

5.  The  cylinder  takes  the  place  of  at  least  two  assistants.  The  operation 
could  readily  be  performed  without  an  assistant. 

6.  It  prevents  escape  of  intestinal  contents  and  hence  dispenses  with  the 
injurious  clamps  or  the  fingers  of  assistants. 

7.  The  entire  operation,  exclusive  of  suture  of  the  abdominal  wall,  can 
be  performed  on  dogs  in  five  or  six  minutes  and  probably  in  less  time. 

The  results  should,  I  believe,  be  better  than  by  any  method  hitherto 
devised. 


PLATE  X 


Presection-stikhes. 


PLATE  XI 


l^-,/ 


\ 


PLATE  XII 


PLATE  XIII 


J 


PLATE  XIV 


H 


G^    ]3/J«Z.,^. 


END-TO-END  SUTURE  OF  THE  INTESTINE  BY  A  BULKHEAD 
METHOD ' 

PRELIMINARY  COMMUNICATION 

Soiling  is  undoubtedly  an  important  contributing  factor  in  the  mortality 
attending  end-to-end  suture  of  the  large  bowel,  but  it  will  not  definitely  be 
known  just  how  important  this  factor  has  been  until  it  can  be  entirely  elimi- 
nated. Of  the  various  methods  devised  to  avoid  the  escapement  of  intestinal 
contents  during  the  operation  of  circular  resection  of  the  intestine,  those 
of  Parker  and  Kerr  and  of  Moszkowicz  deserve  especial  mention.  If  the 
basting  stitch  feature  of  the  Parker-Kerr  operation  were  altogether  omitted, 
and  the  walls  of  the  gut  brought  together  by  the  first  row  of  sutures  over 
the  narrow  clamp  which  these  surgeons  have  devised,  their  operation  and 
that  of  Moszkowicz  would  be  almost  identical.  I  have  sent  to  Vienna  for 
the  Moszkowicz  clamps,  and  may  at  another  time  be  able  to  report  results 
of  trials  on  man  and  animals  of  these  beautifully  constructed  instruments. 

For  the  large  intestine  the  circular  suture  or  end-to-end  anastomosis 
would,  if  equally  safe,  be  conceded  to  be  the  ideal  method ;  occasionally  it  is 
the  only  feasible  one  in  cases  of  resection  of  the  large  bowel. 

The  problem  of  making  an  end-to-end  anastomosis  in  a  manner  more 
nearly  ideal  has,  for  the  past  six  or  eight  months,  been  for  me  a  constantly 
recurring  one.  There  has  been  a  fascination  in  the  difficulties  presented 
by  it.  Repeatedly  certain  steps  of  the  problem,  which  have  seemed  to  be 
solved  on  paper,  have  proved  on  experimentation  to  be  much  more  difficult 
of  solution  than  had  been  supposed. 

As  to  the  mere  exsection  of,  say,  a  loop  of  bowel,  this  can  be  carried  out 
as  cleanly  and  as  aseptically  as  the  resection,  for  example,  of  the  appendix. 
Did  it  suffice  merely  to  sew  together  the  abutted  ends  of  the  gut,  each  end 
having  been  treated  after  the  manner  of  an  appendix  stump,  the  problem 
would  seem  to  be  solved.  The  intestinal  wall  having  been  crushed  and 
reduced  to  its  submucosa,  firmly  ligated  and  divided  with  the  Paquelin 
cautery,  the  division  of  the  gut  is  aseptically  accomplished.  The  two  free 
ends  can  now  be  abutted  and  sutured  without  manifest  flaw  in  the  technique. 
But  a  double  diaphragm  remains  which  would  impede  for  a  long  time  the 

1  Presented  at  the  American  Surgical  Association,  Washington,  D.  C,  May  3-5,  1910. 
Tr.  Am.  Surg.  Ass.,  Phila.,  1910,  xxviii,  256-261.   (Reprinted.) 


234  BULKHEAD  SUTURE  OF  INTESTINE 

passage  of  intestinal  contents,  even  if  the  ligatures  employed  in  the  tying 
off  of  the  gut  could  be  relied  upon  to  melt  away  or  disappear  in  a  desired 
period.  In  other  words,  the  amount  turned  in  of  the  intestinal  wall  by  such 
a  method  is  too  great. 

These  diaphragms,  which  in  some  of  our  experiments  were  reduced  to  the 
submucosa,  may  be  charred  by  the  cautery  *  in  such  a  manner  that  they  will 
ultimately  slough  away,  but  the  process  of  separation  of  tissue  so  dense  is 
very  slow,  and  the  time  required  for  its  accomplishment  uncertain.  One 
experiment  was  made  by  this  method :  the  dog  recovered  without  symptoms 
of  obstruction,  and  is  now  in  good  health.  But  a  satisfactory  result  could 
not  be  expected  uniformly  to  attend  such  procedure. 

To  eliminate  this  diaphragm,  I  devised  a  sharp-edged  punch,  with  the 
idea  of  introducing  it  at  a  higher  point  in  the  bowel  through  a  lateral  open- 
ing, slipping  it  down  to  the  diaphragm,  and,  pressing  it  through  this  obstruc- 
tion and  into  a  cork  introduced  per  anum,  to  withdraw  both  cork  and  punch 
by  means  of  a  string  attached  to  the  former.  This  method  was  not  tested, 
for  at  this  juncture  Dr.  Gatch,  who  has  assisted  me  in  all  these  experiments, 
came  to  the  rescue  with  a  suggestion  much  better,  altogether  novel,  and  one 
which  may  prove  to  be  the  key  to  the  best  solution  for  this  particular  form 
of  procedure.  He  proposed  that  the  bowel  ends,  invaginated  over  a  con- 
trivance like,  for  example,  the  Harrington  collapsible  hammer,  be  redivided 
by  the  cautery  beyond  an  encircling  ligature  which  should  bind  the  gut 
firmly  to  the  hammer.  The  end-to-end  suture  would  then  be  made,  and 
finally  the  hammer  collapsed. 

To  invaginate  and  redivide  the  gut  seemed  to  me  a  very  happy  thought 
and  one  which  promised  well  for  the  disposition  of  the  diaphragms.  It  was 
obvious,  however,  that  the  hammer  was  not  the  ideal  device  for  the  purpose. 
It  appeared  desirable  that  each  of  the  divided  intestinal  ends  should  be 
treated  independently  of  the  other,  for  only  in  this  way  could  the  surfaces 
be  properly  approximated  for  suturing.  If  tied  to  a  hammer-like  device,  the 
ends  of  the  bowel  after  having  been  burnt  would  not  only  not  be  in  contact, 
but  would  be  separated  by  an  interval  so  great  as  to  prohibit  the  employ- 

1  Four  or  five  years  ago.  during  the  house-surgeonship  of  Dr.  W.  F.  Iff.  Sowers, 
and  with  his  assistance,  I  performed  one  or  two  gastroenterostomies  on  the  human 
subject  with  the  aid  of  the  Paquelin  cautery.  The  posterior  rows  of  stitches  having 
been  taken,  the  muscular  coats  of  stomach  and  intestine  were  divided  and  stripped 
back  so  as  to  allow  of  sufficient  exposure  of  the  submucosa.  This  coat  was  then 
burned  with  the  cautery,  but  I  was  in  neither  instance  altogether  satisfied  as  to  its 
destruction  until  I  had  actually  perforated  it  with  the  Paquelin,  and  so  defeated  the 
end  in  view,  which  was  to  avoid  entering  either  bowel  concerned  in  the  anastomosis 
in  the  course  of  the  operation. 


BULKHEAD  SUTURE  OF  IXTESTIXE  235 

ment  of  a  continuous  stitch  for  the  reason  that  the  turning  in  of  too  much 
bowel  would  be  necessitated.  Xor  could  an  interrupted  suture  be  used  with 
the  idea  of  collapsing  the  hammer  before  the  stitches  were  drawn  home, 
because  with  the  disjunction  of  the  hammer  the  encircling  ligatures  would 
be  loosened,  and  thus  the  protecting,  invaginated  diaphragms  be  freed, 
and  the  escape  of  intestinal  contents,  and  hence  soiling,  permitted. 

Eings  of  very  thin  metal  were  tested.  These  were  made  broad  enough  to 
admit  of  being  deeply  grooved  or  guttered  on  the  circumference  for  the 
reception  of  the  bowel  with  its  confining  ligature,  and  were  equipped  with 
a  little  radial  spur  within  to  facilitate  holding  and  so  prevent  their  rotation. 
But,  for  the  crushing  of  the  rings  with  a  concavo-convex  rim,  even  of  lead 
ones,  too  great  force  was  required,  a  force  which  occasioned  trauma  of  the 
bowel.  Furthermore,  the  tendency  on  compressing  the  rings  was,  of  course, 
to  an  elliptical  form,  which  did  not  permit  the  disengagement  of  the  encir- 
cling ligatures ;  and  the  indenting  or  sectoroid  form  of  collapse  was  attained 
only  with  greater  damage  to  the  bowels.  And  even  when  indentation  of  the 
rings  was  satisfactorily  accomplished,  they  were  not  easily  released  from 
the  embrace  of  the  encircling  thread. 

So  we  gave  our  attention  to  soluble  rings,  and  Dr.  Gatch  produced  hard 
disks  of  sugar,  thick  lozenges,  which  he  had  grooved  on  the  edge.  We  experi- 
enced, however,  great  difficulty  in  engaging  these  with  the  ligature.  The 
intestinal  peristalsis  and  the  slipperiness  of  the  peritonaeal  surfaces  and  of 
the  moistened  sugar  contributed  to  the  difficulty  of  maintaining  the  plane 
surfaces  of  the  sugar  disk  at  right  angles  to  the  long  axis  of  the  bowel. 

It  then  occurred  to  me  to  produce  the  invagination  by  means  of  a  soluble 
cylinder  or  rod,  which,  grooved  at  regular  intervals  for  the  reception  of  the 
doubled  wall  of  the  gut,  might,  with  the  Paquelin  cautery,  be  burned  through 
together  with  the  folded  gut.  Sticks  of  candy  and  of  extract  of  licorice, 
being  easily  available,  were  employed,  and  the  result  of  the  first  trial  with 
candy  was  encouraging.  The  division  with  the  cautery  being  easily  and 
accurately  accomplished,  each  end  of  the  bowel  was  thus  securely  plugged 
with  what  might  be  termed  a  bulkhead  of  sugar;  these  warm,  sticky  bulk- 
heads were  pressed  together,  and,  adhering  to  each  other  with  considerable 
firmness,  possibly  assisted  the  act  of  suturing,  which  happened  to  terminate 
precisely  at  the  moment  that  the  sugar  cylinders  had  melted  sufficiently 
to  liberate  the  finger-cot-like  diaphragms  or  invagination  of  bowel.  So  we 
congratulated  ourselves  on  the  success  of  our  bulkhead  method.  Our  satis- 
faction was  of  short  duration,  for  at  the  next  experiment,  performed  a  few 
days  later,  we  were  not  so  lucky  in  engaging  the  grooves  either  on  the  candy 
or  licorice  sticks.  So  I  decided  that  it  would  facilitate  the  execution  of  the 
procedure  to  have  a  soluble  cylinder  provided  with  a  number  of  flanges,  for 


236  BULKHEAD  SUTTEE  OF  INTESTINE 

no  difficulty  could  be  experienced  in  binding  the  gut  to  the  cylinder  between 
two  of  these  flanges.  The  gut  and  cylinder  might  then  be  divided  close  to 
the  ligature. 

After  having  a  brass  model  constructed  to  serve  as  the  positive  for  the 
mould,  it  occurred  to  me  that  it  would  greatly  simplify  matters,  doing  away 
with  the  necessity  for  a  mould,  to  make  the  flanges  of  rubber — these  to  be 
slipped  on  a  smooth  cylinder.  So  rings  were  cut  from  a  catheter  of  the 
proper  size  and  sticks  of  candy  were  armed  with  these  as  flanges.  Thus 
another  difficulty  was  overcome. 

But  the  procedure  needed  refinement.  It  would  be  better  to  eliminate  the 
burning  of  so  much  sugar  or  other  materials  of  which  the  stick  might  ulti- 
mately be  composed.  A  hollow  cylinder  would,  I  thought,  be  preferable  to 
a  solid  one.  But  how  to  prevent  the  too  sudden  collapse  of  such  a  tube  was 
the  question.  We  might  mount  closely  fitting  gelatin  capsules  on  metal 
mandrils,  over  all  draw  the  rubber  flanges,  and,  burning  through  the  gelatin, 
remove,  on  completion  of  the  suture,  the  supporting  mandrils.  We  made 
trial  of  gelatin  capsules  heavily  coated  with  shellac  to  prevent  them  from 
dissolving  too  rapidly,  and  supported  them  on  snugly  fitting  mandrils.  But 
the  heat  of  the  cautery  made  them  adhere  so  firmly  to  the  brass  mandrils 
that  they  could  not  be  dislodged  nicely:  and  the  capsules,  when  employed 
without  the  mandrils,  softened  on  the  application  of  the  cautery  knife,  and 
hence  lost  the  required  firmness.  So  the  licorice,  which  we  found  could  be 
turned  on  a  lathe,  was  again  resorted  to,  this  time  in  the  form  of  grooved 
rods.  The  determination,  even  through  a  thick  intestinal  wall,  of  the  situa- 
tion of  a  groove  is  made  easy  by  the  use  of  rubber  bands  placed  close  behind 
the  edges  of  the  grooves.  As  the  ligature  encircling  the  invaginated  bowel 
in  front  of  the  rubber  flange  is  being  drawn  tight,  the  invaginating  rod  is 
drawn  outward  until  its  band,  having  been  brought  into  proper  relation  with 
the  ligature,  compels  the  latter  to  find  the  groove.  In  the  taking  of  the 
stitches,  which  may  be  continuous  or  interrupted,  as  preferred  by  the  opera- 
tor, one  must  not,  of  course,  include  in  them  the  invaginated  portion. 

With  the  recognition  of  this  danger,  such  mishap  may  with  certainty  be 
avoided  by  sliding  into  place,  with  the  fingers,  the  surfaces  to  be  brought  in 
contact  for  suturing.  The  support  furnished  by  the  still  undissolved  bulk- 
heads makes  it  possible  for  the  assistant  to  perform  this  act  of  further  in- 
vagination with  great  nicety;  furthermore,  tug  on  the  intestinal  wall, 
incident  to  the  taking  of  each  new  stitch  of  the  continuous  or  interrupted 
variety,  and  which  is  ordinarily  exerted  in  drawing  surfaces  of  intestine  into 
contact  by  stitching,  is  avoided  by  this  act  of  sliding  the  bowel  walls  into 
the  desired  position. 


BULKHEAD  SUTURE  OF  INTESTINE  237 

Our  experiments,  though  uniformly  successful  with  the  above  described 
method,  have  not  been  sufficient  in  number  to  justify  our  unqualified 
endorsement  of  it. 

I  would  again  call  attention  to  the  importance  of  the  submucosa  as  a  coat 
to  be  included  in  all  the  stitches,  and  to  the  desirability  of  avoiding,  as  much 
as  possible,  penetration  into  the  lumen  of  the  bowel  in  the  taking  of  the 
suture. 


A  BULKHEAD  SUTUEE  OF  THE  INTESTINE1 

It  would,  I  think,  be  conceded  that  end-to-end  anastomosis  of  the  intes- 
tine should  be  the  method  of  choice  if  it  were  as  safe  as  the  lateral  anasto- 
mosis. Occasionally  the  circular  suture  is  the  only  feasible  one. 

Soiling,  unquestionably,  contributes  to  the  mortality  attending  the  cir- 
cular suture,  particularly  of  the  large  bowel,  but  how  important  this  factor 
is  cannot  be  definitely  determined  until  it  shall  have  been  completely 
eliminated. 

The  problem  of  making  an  end-to-end  anastomosis  in  a  manner  more 
nearly  ideal,  namely,  in  truly  aseptic  fashion,  has  for  many  years  confronted 
surgeons,  but  only  during  the  past  two  years,  and  since  having  had  in  mind 
some  investigations  involving  the  making,  simultaneously,  of  a  number  of 
resections  of  the  gut  have  I  given  the  matter  serious  consideration.  In  ex- 
perimentation of  this  kind,  the  failure  of  one  suture  means  disaster  to  all, 
and  the  loss  perhaps  of  half  a  day's  work. 

That  the  solving  of  this  problem  is  also  worth  while  from  the  humani- 
tarian point  of  view  is  indubitable.  In  the  winter  of  1909-10,  assisted  by 
Dr.  Willis  D.  Gatch,  I  made  a  number  of  experiments  on  dogs  in  the  hope 
that  we  might  contribute  something  toward  the  solution  of  this  problem 
which  became  the  more  fascinating  as  the  difficulties  presented  by  it  in- 
creased. Eepeatedly  certain  steps  in  a  procedure  which  seemed  on  paper 
and  at  night  to  be  solved  could  be  found,  when  tested  at  the  operating  table 
in  the  morning,  to  be  as  far  from  solution  as  ever. 

As  to  the  simple  excision  of  a  loop  of  bowel,  this  can  be  carried  out  as 
cleanly  and  as  aseptically  as  the  resection  of  the  appendix.  If  it  sufficed 
merely  to  sew  together  the  abutted  ends  of  the  gut,  each  end  having  been 
treated  after  the  manner  of  an  appendix  stump,  the  problem  would  seem  to 
be  solved.  The  wall  of  the  bowel  having  been  reduced  to  its  submucous  coat 
by  crushing  or  otherwise,  firmly  ligated,  and  cut  through  with  the  Paquelin 
cautery,  the  division  of  the  gut  is  accomplished  aseptically.  The  two  free 
ends  can  now  be  abutted  and  sewed  together  without  manifest  flaw  in  the 
technique.  But  a  double  diaphragm  remains  to  impede  for  a  long  time  the 
advance  of  intestinal  contents  even  if  the  ligatures  employed  in  the  tying 
off  of  the  gut  could  be  relied  upon  to  melt  away  with  the  desired  promptness. 
In  other  words,  the  amount  turned  in  of  the  intestinal  wall  is  too  great. 

1  Received  for  publication  January  16,  1912. 
J.  Exper.  M.,  Lancaster,  Pa.,  1912,  xv,  216-224.    (Reprinted.) 
238 


BULKHEAD  SUTUEE  OF  INTESTINE  239 

Diaphragms  like  these,  which  in  some  of  our  experiments  were  reduced  to 
the  submucosa,  may  be  charred  by  the  cautery  in  such  a  way  that  they  will 
ultimately  slough,  but  the  process  of  separation  of  tissue  so  dense  is  too 
slow.  One  experiment  was  carried  out  on  this  plan.  The  animal  recovered 
with  the  aid  of  a  prolonged  fast  without  symptoms  of  obstruction.  But  a 
satisfactory  result  could  not  be  expected  uniformly  to  attend  such  procedure. 

Only  a  few  experiments  had  been  undertaken  when  Dr.  Gatch  made  a 
suggestion  which  is  altogether  novel  and  may  prove  to  be  the  key  to  the 
situation.  He  proposed  that  the  bowel  ends,  occluded  in  the  described  man- 
ner, be  invaginated  over  a  contrivance  like  the  Harrington  collapsible  ham- 
mer and  redivided  by  the  cautery  beyond  encircling  ligatures  which  should 
bind  the  gut  firmly  to  the  instrument.  The  end-to-end  suture  would  then 
be  made  and  the  hammer  ultimately  collapsed. 

To  invaginate  and  redivide  the  gut  seemed  to  me  to  be  a  particularly 
happy  idea  and  one  which  promised  much  toward  the  elucidation  of  the 
whole  problem.  It  was  obvious,  however,  that  a  contrivance  of  the  order  of 
the  hammer  could  not  be  suitable,  for  the  invaginated  ends,  after  having 
been  burned  away,  would  be  too  far  apart  for  the  act  of  stitching  them 
together.  An  instrument  might,  I  grant,  be  devised  which  would  admit  of 
the  approximation  of  the  seared  ends,  but  I  think  it  would  be  better  for 
various  reasons  to  be  able  to  treat  each  gut-end  separately.  On  a  hammer- 
like instrument  one  could  not,  for  example,  invaginate  the  gut  indefinitely 
nor,  having  burned  off  the  ends  beyond  the  ligatures,  repeat  the  process  at 
another  point  should  there  be  indications  for  this. 

Believing,  therefore,  that  it  was  desirable  to  be  able  to  treat  each  of  the 
ends  separately,  rings  of  very  thin  soft  metal  were  tested.  These  were  made 
broad  enough  to  carry  a  groove  on  their  circumference  for  the  reception  of 
the  bowel  with  its  confining  ligature  and  were  provided  with  a  little  radial 
spur,  within,  to  facilitate  the  holding  of  the  rings.  But  for  the  crushing  of 
the  rings,  even  of  lead  ones,  with  their  concavo-convex  rims,  the  force  re- 
quired was  so  great  that  it  occasioned  trauma  of  the  bowel. 

Furthermore,  the  tendency  on  compressing  the  rings  was,  of  course,  to 
an  elliptical  form  which  did  not  permit  the  disengagement  of  the  encircling 
ligatures ;  and  the  indenting  or  sectoroid  form  of  collapse  was  attained  only 
with  still  greater  damage  of  the  intestine.  And  even  when  indentation  of 
the  rings  was  satisfactorily  accomplished,  they  were  not  easily  released  from 
the  embrace  of  the  binding  threads. 

Then  we  tried  soluble  rings,  and  Dr.  Gatch  provided  hard  disks  of  sugar — 
thick  lozenges  which  he  had  grooved  on  the  circumference.  We  experienced, 
however,  great  difficulty  in  engaging  these  with  the  ligature.  The  intestinal 
peristalsis  and  slipperiness  of  the  peritonaeal  surfaces  and  of  the  moistened 


240  BULKHEAD  SUTUKE  OF  IXTESTIXE 

sugar  contributed  to  the  difficulty  of  maintaining  the  plane  surface  of  the 
sugar  disk  at  right  angles  to  the  long  axis  of  the  bowel. 

At  last  it  occurred  to  me  to  produce  the  invagination  by  means  of  a  soluble 
cylinder  or  rod  which,  grooved  at  regular  intervals  for  the  reception  of  the 
doubled  wall  of  the  intestine,  might  be  burned  through  together  with  the 
invaginated  gut.  Sticks  of  candy  and  extract  of  licorice,  being  easily  avail- 
able, were  employed,  and  the  result  of  the  first  trial  with  candy  was  encour- 
aging. The  division  with  the  cautery  being  easily  and  accurately 
accomplished,  each  end  of  the  bowel  remained  securely  plugged  with  what 
might  be  termed  a  bulkhead  of  sugar.  These  warm,  sticky  bulkheads  were 
pressed  together  and,  adhering  to  each  other  with  considerable  firmness, 
possibly  assisted  the  act  of  suturing,  which  happened  to  terminate  precisely 
at  the  moment  that  the  sugar  had  melted  sufficiently  to  liberate  the  finger- 
cot -like  diaphragms  or  invaginations  of  the  bowel  wall. 

Our  satisfaction  was  of  brief  duration,  for  at  the  next  experiment  we  were 
not  so  lucky  in  engaging  the  grooves  on  the  sticks,  whether  of  candy  or 
licorice,  so  I  decided  to  arm  the  cylinder  with  a  number  of  flanges  which 
might  easily  be  palpated  through  the  wall  of  the  intestine,  being  confident 
that  no  difficulty  would  be  experienced  in  binding  the  gut  to  the  cylinder 
between  two  of  these  flanges. 

After  having  had  a  brass  model  constructed  to  serve  as  the  positive  for 
mould,  it  seemed  to  me  that  it  would  greatly  simplify  matters,  discarding  the 
mould  idea,  to  make  flanges  of  rubber — these  to  be  slipped  on  a  smooth, 
soluble  cylinder. 

So  rings  of  rubber  were  cut  from  a  catheter  of  the  proper  size  and  sticks 
of  licorice  armed  with  these  as  flanges. 

Thus  another  difficulty  was  overcome.  But  the  procedure  was  still  in  need 
of  great  refinement.  A  hollow  cylinder  would,  I  thought,  be  preferable  to 
the  solid  ones,  for  the  burning  of  a  solid  rod  of  licorice  or  sugar  was  a  dis- 
agreeable and  clumsy  performance.  Hollow  cylinders  of  hard  gelatin  coated 
with  shellac  were  mounted  on  brass  mandrels,  over  all  were  drawn  the  rubber 
rings,  and  the  gelatin  was  burned  through  to  the  brass  mandrels.  But  the 
heat  of  the  cautery  made  the  gelatin  adhere  to  the  mandrels  so  that  the 
latter  could  not  be  nicely  dislodged ;  and  the  capsules  when  employed  with- 
out the  mandrels  lost  the  r°quired  firmness  on  being  cut  through  with  the 
cautery  knife. 

Then  the  licorice  was  again  resorted  to.  I  found  that  it  could  be  turned 
in  perfect  cylinder  form  and  also  grooved  on  a  lathe.  Close  to  the  edge  of 
each  groove  on  the  licorice  rod,  a  rubber  flange  was  placed.  The  determina- 
tion of  the  situation  of  each  groove  was  made  easy  by  the  use  of  the  rubber 
bands  which  could  be  distinctly  felt  through  the  intestinal  wall  even  when 


BULKHEAD  SUTURE  OF  INTESTINE 


241 


peristalsis  was  taking  place.  As  the  ligature  encircling  the  invaginated  in- 
testinal wall  in  front  of  a  rubber  flange  was  being  tightened,  the  invaginating 
rod  of  licorice  was  slowly  withdrawn  until  the  ligature  became  engaged  in 
the  groove  intended  for  it,  as  it  was  compelled  to  do  by  the  rubber  flange. 

The  procedure  had  reached  this  stage  in  its  development  when,  at  the 
meeting  of  the  American  Surgical  Association  in  the  spring  of  1910/  I  re- 
ported the  progress  which  had  been  made. 

Since  then  the  method  has  been  decidedly  improved  by  the  substitution 
of  paper  cones  for  the  licorice  rods. 


WoocJmandrel 


Fig.  30. — One  of  the  Ends  of  the  Divided  Gut  is  Being  Invaginated  by  the  Wooden 
Mandrel  Which  Carries  the  Paper  Cone. 


Cones  of  any  desired  size  and  thickness  can  be  manufactured  in  a  few 
minutes  by  twisting  and  pasting  together  narrow  strips  of  paper,  one  after 
the  other,  on  a  conical  form  of  wood,  the  latter  to  be  used  later  as  a  mandrel. 
The  paper  cones  are  armed,  each  with  a  rubber  flange  or  ring  cut  from  a 
catheter. 

The  operation  is  then  performed  as  follows:  The  peritonaeal  and  mus- 
cular coats  are  divided  and  stripped  back  on  the  submucosa  far  enough  to 
enable  the  operator  to  place  two  ligatures  around  the  gut  and  to  divide  be- 
tween these  with  the  hot  knife.  To  prevent  the  slipping  of  these  ligatures 
which  are  of  fine  silk,  and  threaded  on  straight  needles,  they  are  made  to 

2  Tr.  Am.  Surg.  Ass.,  Phila.,  1910,  xxviii,  256-261.   [W.  C.  B.] 
17 


242 


BULKHEAD  SUTUEE  OF  INTESTINE 


engage,  but  not  completely  pierce,  the  submucosa  at,  say,  three  or  four  points 
before  being  tied. 

The  paper  cone  armed  with  the  rubber  ring  and  mounted  on  the  mandrel 
of  wood  is  carried  by  the  latter  into  the  invagination  in  the  manner  shown 
in  Pig.  30.  When  invagination  to  the  desired  extent  has  been  made,  a 
ligature  of  strong  silk  is  tied  with  force,  binding  the  gut  to  the  cone  distal 
to  the  rubber  flange.  Both  ends  of  the  intestine  having  been  treated  in  this 
manner,  they  are  burned,  close  to  the  ligatures,  down  to  and  through  the 
paper  cones  (Fig.  31).  The  invaginated  portion  of  bowel  constitutes  the 
bulkhead,  the  paper  cones  serving  merely  to  sustain  the  pressure  of  the 
confining  ligatures. 


Fig.  31.— On  One  Side  the  Gut  Has  Been  Partially  Burned  Through 
by  the  Cautery  Knife. 


The  surgeon  has  not,  until  now,  concerned  himself  with  the  ligation  of  the 
mesenteric  vessels.  The  blood  supply  having  been  undisturbed  is,  of  course, 
perfect  up  to  the  exact  site  of  the  ligature.  Precisely  at  this  point  the  mesen- 
tery is  transfixed  close  to  the  bowel  with  one  of  the  fine  milliner's  needles 
carrying  a  thread  for  the  circumvection  ligature  which  is  to  occlude  the 
ultimate  little  mesenteric  vessel.  The  larger  vessels  supplying  the  gut  distal 
to  this  point  are  now  tied  off  by  circumvection  ligatures  carried  by  needles 
of  the  kind  named.    The  end-to-end  anastomosis  is  then  made  *  with  the 

*  Caution.  Neither  in  the  act  of  suturing  nor  at  any  time  after  the  final  division  of 
the  bowel,  should  one  push  so  hard  against  the  edges  of  the  cones  as  to  dislocate  them 
into  the  intestinal  lumen.  Should  there  be  a  tendency  to  this  dislocation,  it  may  be 
obviated  by  winding  a  ligature-thread  around  the  cone  a  few  millimetres  distal  to  the 
rubber  flange,  room  being  left  between  the  flange  and  the  thread  for  the  application 
of  the  binding  ligature. 


BULKHEAD  SUTUKE  OF  INTESTINE 


243 


continuous  mattress  suture,  described  by  Dr.  Hayward  "W.  Cushing  and 
myself,  reinforced  here  and  there  by  an  interrupted  stitch  (Figs.  32  and  33). 
Particular  attention  is  called  to  the  possibility  of  a  calamity  which  even 
those  who  are  not  novices  might  not  always  avert  unless  they  exercised 
especial  care  to  avoid  it.  I  refer  to  the  danger  of  including  in  the  suture 
the  wall  of  the  invaginated  bowel.  This  error  will  not  occur  if  the  intussus- 
cipiens  on  each  side  is  slid  a  little  further  over  its  intussusceptum  or  bulk- 
head by  the  fingers  of  an  assistant,  as  shown  in  Fig.  33.  The  stitching  being 
completed,  it  remains  merely  to  crush  the  paper  cones  with  the  fingers.  By 
this  act,  the  invagination-bulkheads  are  liberated  and  the  lumen  of  the 
bowel  is  reestablished.    I  usually  push  the  freed  upper  cone  a  foot  or  two 


Fig.  32. — The  Ends  of  Intestine  and  the  Paper  Cones,  Having  Been  Divided  With 
the  Cautery  Knife  are  Apposed,  the  Invagination  Bulkheads  Being  Held  Firmly 
in  Place  by  the  Encircling  Ligatures. 


centrally  along  the  intestine  so  that  it  may  be  better  softened  by  the  time 
it  has  descended  to  the  line  of  suture. 

In  certain  details  the  method  is  still  imperfect.  For  example,  the  size 
and  thickness,  and  the  degree  of  conicity  and  of  impermeability  to  fluids  of 
the  paper  cones  best  suited  to  the  purpose  have  not  been  carefully  deter- 
mined. But  in  our  hands  the  operation  in  its  present  stage  of  development 
proceeds  without  embarrassments.  It  is,  of  course,  probable  that  something 
better  suited  to  the  purpose  than  paper  cones  will  be  found. 

Advantages  of  the  Method. — 1.  It  is  aseptic,  except  as  contamination  may 
occur  from  stitches  which  of  necessity  or  by  accident  have  been  carried  into 
the  lumen  of  the  intestine. 

2.  The  gut  may  be  invaginated  to  any  extent,  and  even  after  the  binding 
ligature  has  been  applied,  if  it  should  seem  desirable  to  invaginate  further, 


244 


BULKHEAD  SUTURE  OF  INTESTINE 


BULKHEAD  SUTTJEE  OF  INTESTINE  245 

the  process  may  be  continued  indefinitely,  without  redivision  of  the  bowel, 
after  merely  cutting  the  ligatures. 

3.  Precise  control  of  the  blood  supply. 

4.  Eelief  from  the  annoyance  of  clamps  of  any  kind,  which  is  particu- 
larly to  be  desired  when  the  operator  is  working  in  places  difficult  of  access. 

5.  The  bowel-ends  are  reduced  to  the  same  size,  which  is  desirable  for  the 
end-to-end  suture. 

6.  The  absolute  certainty  with  which  the  mesenteric  border  is  turned  in. 

7.  Greater  ease  of  stitch-taking,  particularly  of  the  mesenteric  border. 

8.  Its  simplicity. 

How  often  have  we  heard  the  merits  of  new  methods  of  intestinal  suture 
extolled  almost  in  the  same  words ! 

The  working  out  of  the  problem  has  at  least  been  interesting. 

This  procedure  should  be  practised  repeatedly  on  animals  before  being 
undertaken  on  the  human  subject. 

Most  of  the  experiments  were  conducted  without  aseptic  precautions,  and 
the  dogs  were  killed  on  the  operating  table. 

Three  were  operated  upon  aseptically,  and  these  were  kept  under  observa- 
tion for  several  weeks.  All  made  uninterrupted  recoveries,  and  the  intra- 
abdominal findings  at  autopsy  were  ideal. 

I  have  not,  for  several  years,  had  occasion  to  make  an  end-to-end  suture 
of  the  intestine  in  the  human  subject,  and  am  not  sure  that  I  should  venture, 
without  further  experimentation  on  animals,  to  employ  the  bulkhead  suture. 
The  procedure  is  not,  as  yet,  sufficiently  perfected  to  be  "  marketable,"  and 
this  is  one  of  my  reasons  for  desiring  to  publish  it  in  the  Journal  of  Experi- 
mental Medicine  rather  than  in  a  periodical  devoted  to  surgery. 


AX  EXD-TO-EXD  ANASTOMOSIS  OF  THE  LAEGE  IXTESTLXE 
BY  ABITTTIXG  CLOSED  EXPS  AXD  PrXCTTEIXG  THE 
DOUBLE  DIAPHEAGM  WITH  AX  IXSTBOIEXT  PASSED 
PEE  EECTUM1 

My  interest  in  end-to-end  suture  (circular  enterorrhaphy)  of  the  intes- 
tine has  had  its  exuviation  periods.  The  impulse  for  the  current  experi- 
mental study  was  given  by  experiences  in  the  case  of  a  friend  upon  whom 
in  the  course  of  a  very  difficult  and  quite  desperately  serious  operation  for 
uterine  and  ovarian  neoplasms  it  became  necessary  to  excise  a  portion  of  the 
sigmoid  flexure  of  the  colon  and  to  perform  within  the  pelvis  an  end-to-end 
suture  of  this  boweL  The  operation,  according  to  the  testimony  of  competent 
observers,  was  performed  in  a  masterly  manner,  the  competent  surgeon 
having  the  secure  foundation  that  experimental  work  in  the  laboratory  alone 
can  give.  A  faecal  fistula  through  which  escaped  all  of  the  intestinal  contents 
formed  at  the  line  of  the  circular  suture,  which  presumably  broke  down  more 
or  less  completely.  For  five  weeks  or  more  the  patient  had  rigors  and  high 
fever,  and  when  her  life  was  almost  despaired  of  the  entire  picture  changed 
spontaneously  within  an  hour  or  two  and  a  rapid  and  uninterrupted  con- 
valescence followed.  The  operator  was  impressed  with  the  filthiness  of  the 
methods  of  performing  end-to-end  anastomosis  of  the  colon,  particularly  in 
ruation.  The  immediate  incentive  for  again  taking  up  the  subject  of 
intestinal  suture  was,  as  I  have  said,  the  outcome  of  weeks  of  anxious  obser- 
vation of  this  stormy  convalescence. 

The  allotted  time  permits  only  the  briefest  reference  to  salient  facts  in 
the  history  of  intestinal  suture,  and  I  shall  confine  myself  to  the  considera- 
tion of  advances  which  to  me  seem  modern,  ancient  though  they  may  appear 
to  those  of  you  born  years  after  this  hospital  was  opened. 

In  the  autumn  of  1886,  in  the  laboratory  of  Dr.  Welch  and  with  the 
nee  of  Dr.  Mall,  I  undertook  the  study  of  intestinal  suture.  Surely 
no  one  ever  worked  under  happier  auspices  or  with  more  stimulating  com- 
panions. A  few  years  later  Senn  was  experimenting  with  his  plates  of  car- 
tilage, and  then  Abbe  with  catgut  rings.  The  fact  that  such  contrivances 
could  have  been  seriously  advocated  by  representative  surgeons  registers  the 
crudity  of  intestinal  surgery  in  our  country  about  30  years  ago. 

■  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  December 
6.  1920. 
Johns  Hopkins  Hosp.  BulL,  Bait.,  1921,  xxarii,  98-99.    (Reprinted J 
246 


ASEPTIC  INTESTINAL  ANASTOMOSIS  247 

Our  experiments  were  conducted  almost  daily  for  about  six  months.  What 
they  yielded  is  recorded  in  the  papers  of  Mall  and  myself.  Pertinent  to  our 
present  study  is  the  fact  that  the  importance  of  the  submucosa  was  recog- 
nized. I  have  only  recently  discovered  that  Gross  had  mentioned  this  coat  in 
1843,  but  in  the  intervening  years  its  very  existence  was  altogether  over- 
looked, and  every  surgeon  believed  that  it  was  possible  to  take  and  advocated 
the  taking  of  a  peritonaeal  stitch  for  the  final  row.  The  necessity  for  includ- 
ing in  each  stitch  at  least  a  part  of  the  submucous  coat  being  now  recognized, 
surgeons  have  concentrated  their  attention  on  the  devising  of  a  suture  which 
should  be  as  nearly  as  possible  bacteriologically  clean.  Numerous  instru- 
ments and  methods  designed  to  lessen  the  amount  of  contamination  have 
been  contrived  but  with  so  little  success  that  the  end-to-end  suture  is  quite 
universally  performed  today  essentially  as  it  was  by  Czerny  in  1878  or  by 
myself  in  1886,  or  by  Connell  in  1892.  The  Murphy  button  (December, 
1892)  will  in  my  opinion  soon  be  obsolete.  The  several  objections  to  its  use 
which  at  the  outset  were  offered  have  proved  valid,  and  I  would  add  the 
obvious  one,  that  ideal  healing  should  not  be  expected  to  take  place  on  the 
confines  of  sphacelated  tissues.  Nevertheless  this  ingenious  contrivance  has 
enjoyed  a  marvelous  endorsement  both  in  this  country  and  abroad;  it 
tempted  incompetent  surgeons  to  essay  operations  for  which  they  were 
unequipped,  and  made  appeal  to  the  operator  who  overestimated  the  value 
of  time — of  the  time  saved  to  the  patient  and  lost  to  himself.  Senn  in  his 
comprehensive  and  valuable  paper  on  intestinal  suture  calls  attention  to  the 
interesting  fact  that  an  Argentine  surgeon  was  awarded  a  gold  medal  by 
the  Peruvian  Government  for  his  invention  of  a  button  which  in  principle 
is  essentially  the  same  as  Murphy's :  "  A  few  days  ago  I  received  an  inter- 
esting brochure  from  Adelbert  Eamauge,  professor  of  surgery  in  the  medical 
faculty  of  Buenos  Ayres,  entitled  '  Enteroplexie/  a  paper  which  he  read  at 
a  meeting  of  the  International  Medical  Congress  of  South  America,  Janu- 
ary 20,  1893,  and  which  received  the  first  prize,  a  gold  medal,  from  the 
Peruvian  government.  In  this  paper  I  find  the  description  of  an  instrument 
which  is  intended  for  the  same  purpose  as  the  Murphy  button  and  which 
bears  a  strong  resemblance  to  it." 

As  the  bulkhead  suture  of  Dr.  Gatch  and  myself  did  not  prove  to  be 
strictly  an  aseptic  one,  I  finally  abandoned  attempts  to  perform  it.  But  it 
taught  us  and  Dr.  Grey,  who  simplified  it,  that  a  great  amount  of  intestine 
could  safely  be  turned  in — an  amount  greater  than  is  inverted  by  the  proce- 
dure about  to  be  described.  The  remarkable  results  obtained  by  Gatch,  with 
a  method  which  he  subsequently  developed,  deserve  wider  recognition  and 
furnish  convincing  confirmation  of  the  above  statement  in  regard  to  the 
depth  of  the  flange  which  may  be  turned  in  without  fear  of  causing 
obstruction. 


248  ASEPTIC  INTESTINAL  ANASTOMOSIS 

The  current  experiments  of  Dr.  Holman  and  myself,  although  few,  are 
sufficient  in  number  to  have  demonstrated  the  feasibility  of  the  idea,  which 
was  to  abut  and  sew  together  the  aseptically  closed  ends  of  the  intestine  and 
trust  to  the  rapid  disintegration  of  the  occluding  purse-string  of  fine  catgut 
for  the  reestablishment  of  the  bowel's  lumen.  If  advisable,  a  colostomy  would 
be  made  proximal  to  the  anastomosis.  Dr.  Bloodgood  tells  me  that  his  best 
results  in  resection  of  the  large  intestine  for  carcinoma  have  been  obtained 
in  the  patients  who  on  admission  were  so  ill  that  only  a  colostomy  could  be 
ventured,  and  in  those  already  provided  with  a  preternatural  anus;  and 
Dr.  J.  Shelton  Horsley  in  his  paper  on  "  Eesection  of  the  Caecum  and 
Ascending  Colon  "  has  said  enough  to  indicate  an  inclination  on  his  part  to 
advocate  the  use  of  a  protective  colostomy.  Our  procedure  is  as  follows: 
The  muscular  coats  of  the  intestine  are  stripped  from  the  submucosa  for 
about  2  cm.  towards  the  piece  to  be  resected;  finely  basted,  purse-string 
sutures  of  catgut  are  taken  in  the  submucosa,  and  the  bowel  divided  with  a 
cautery  knife  between  them  at  the  sites  of  election;  then,  with  the  finest 
point  of  a  Paquelin,  the  centres  of  the  stumps  to  be  approximated  are  cau- 
tiously burnt ;  and  now  the  closed,  abutted  ends  of  the  intestine  are  united 
by  mattress  sutures. 

The  first  five  sutures,  alternately  green  and  black  if  one  chooses,  are  used 
as  stays  between  which,  on  the  stretch,  the  supplementary  ones  are  taken. 
Two  of  the  stays  are  placed  very  close  together,  one  on  each  side  of  the 
mesenteric  attachment ;  the  third  is  taken  at  the  free  border  of  the  gut ;  the 
fourth  and  fifth,  one  on  each  side,  midway  between  the  two  borders.  None 
of  the  stay  sutures  is  tied  until  all  of  these  have  been  placed.  Each  inter- 
vening stitch  is  tied  when  made.  The  nearer  the  line  of  suture  to  the  stumps 
the  less,  of  course,  the  amount  of  inturn,  but  the  operator  should  not  let  the 
fear  of  inverting  too  much  deter  him  from  providing  for  the  apposition  of 
sufficiently l)road  peritonaeal  surfaces.  On  the  other  hand,  the  diaphragms 
had  better  not  be  flappish,  although  a  little  slack  is  permissible. 

After  the  above  report  was  made  it  occurred  to  me  that  one  might  easily 
develop  a  method  for  puncturing  the  double  intestinal  diaphragm  from 
below.  A  short  cylinder  of  wood  containing  four  housed  knives  is  introduced 
per  rectum  by  an  assistant  against  whose  manoeuvres  the  operating  field  is 
of  course  protected.  This  cylinder  should  approximately  fill  the  bowel  in 
order  to  center  the  knife  perfectly.  Inside  the  gut  it  is  picked  up  at  the  brim 
of  the  pelvis  by  the  operator  and  pressed  on  to  the  desired  point.  A  second 
short  cylinder,  a  trailer,  threaded  on  a  flexible  guide,  follows  the  first,  to 
enable  the  outside  assistant  to  push  the  latter  to  within  reach  of  the  opera- 
tor's hand.  The  apparatus  may  be  slipped  along  to  any  part  of  the  large 
intestine.  Precise  details  of  the  apparatus  will  be  given  in  a  subsequent 
communication. 


BLIXD-EXD  CIRCULAR  SUTURE  OF  THE  IXTESTIXE,  CLOSED 
ENDS  ABUTTED  AXD  THE  DOUBLE  DIAPHRAGM  PUNC- 
TURED WITH  A  KXIFE  IXTRODUCED  PER  RECTUM  ' 

The  last  word  on  the  subject  of  intestinal  suture  may  some  day  be  written, 
but  surely  not  until  much  experimental  -work  has  been  done  with  an  exact- 
ness not  hitherto  contemplated  in  investigations  of  this  nature.  Authors 
of  text -books  and  of  papers  lend  their  indorsement  to  some  particular  variety 
of  suture  without  offering  plausible  argument  for  their  preference  other  than 
a  certain  measure  of  success  which  has  attended  its  employment  in  their 
hands ;  and  faulty  methods  succeed  so  well  that  interest  in  the  relative  merits 
of  the  details  of  the  various  procedures  has  not  been  sufficiently  aroused  to 
demand  greater  precision  in  the  experimentation  and  the  critical  analysis. 

Who  knows,  for  example,  how  much  of  the  intestinal  wall  should  be 
turned  in ;  whether  two  rows  of  stitching  are  better  than  one ;  whether  the 
suture  should  be  continuous  or  interrupted ;  whether  the  Lembert  or  mattress 
stitch  is  preferable ;  if  the  knots  should  be  on  the  mucous  or  on  the  peritonaeal 
surface;  why  some  stitch-loops  (knots  outside)  fall  into  the  lumen  and 
others  remain  on  the  peritonaeal  surface;  who  has  considered  the  factors 
facilitating  or  delaying  the  release  of  the  inturn ;  and  who,  indeed,  has  en- 
deavored to  estimate  the  weight  of  the  burden  thrown  upon  the  experimentee 
to  counteract  the  operator's  shortcomings  ? 

Assuredly  there  is  no  subject  in  surgery  which  has  received  experimentally 
a  tithe  of  the  labor  devoted  to  intestinal  suture.  Lives  there,  indeed,  a  sur- 
geon who  has  not  made  experiments  in  suturing  the  intestine — if  not  on 
animals,  then  on  man  ? 2  Such  performance  on  the  human  subject  without 
rehearsal  on  animals  is  a  ruthless  play  with  human  life,  advancing  knowledge 
scarce  a  tittle. 

1  Ann.  Surg.,  Phila.,  1922,  xxxvii,  356-364.   (Reprinted.) 

2  In  our  laboratory  operative  courses  for  students  of  The  Johns  Hopkins  Medical 
School  the  leading  topic  from  the  time  of  the  introduction  of  these  exercises  in  1895 
up  to  the  present  year  has  been  intestinal  suture.  I  embrace  this  opportunity  to 
express  my  indebtedness  to  Harvey  Cushing,  for  thirteen  years  my  brilliant  assistant, 
for  his  zeal  in  elaborating  these  courses  and  placing  them  on  such  a  substantial 
basis  that  they  are  now  regarded  as  one  of  the  dominant  features  of  the  surgical 
curriculum  for  the  third-year  medical  students  at  The  Johns  Hopkins  University,  and 
are  being  adopted  by  other  medical  schools  of  this  country. 


250  ASEPTIC  INTESTINAL  ANASTOMOSIS 

Last  winter,  at  one  of  the  monthly  meetings  of  The  Johns  Hopkins  Hos- 
pital Medical  Society,  Doctor  Holman  and  the  writer  reported  *  the  results 
of  a  few  experiments  having  for  their  object  the  development  of  an  end-to- 
end  suture  more  nearly  aseptic  than  had  hitherto  been  devised.  The  bulk- 
head suture  *  had  taught  me  that  without  danger  of  resulting  obstruction, 
the  inturn  of  intestinal  wall  (the  flange)  may  be  much  greater  than  is 
generally  supposed,  so  great  indeed  as  quite  to  fill  the  lumen  of  the  gut; 
and  the  highly  instructive  and  too  little  known  experiments  of  my  former 
assistant,  Dr.  Willis  D.  Gatch,8  convincingly  support  this  assertion. 

In  the  course  of  the  speculations,  which  eventually  led  to  the  development 
of  the  bulkhead  suture,  I  had  entertained  and  discarded  the  idea  of  trusting 
to  the  absorption  of  a  catgut  purse-string  to  reestablish  the  intestinal  lumen 
occluded  by  the  double  diaphragm  of  abutted  closed  ends,  and  wrote  of  it  as 
follows  (I.  c,  p.  217)  :  "  But  a  double  diaphragm  remains  to  impede  for  a 
long  time  the  advance  of  intestinal  contents  even  if  the  ligature  employed 
in  the  tying  off  of  the  gut  could  be  relied  upon  to  melt  away  with  the  desired 
promptness."  Evidently  I  did  not  realize  at  the  time  how  great  the  inturn 
might  safely  be.  Later  we  ascertained  that  the  amount  inverted  by  the 
bulkhead  method  proved  to  be  even  greater  than  in  the  blind-end  suture 
which  it  is  the  purpose  of  this  communication  to  describe,  and  produced  no 
obstruction  nevertheless. 

At  the  outset  of  the  recent  experiments  outlined  in  our  report  to  The 
Johns  Hopkins  Hospital  Medical  Society  last  winter,  I  had  it  in  mind  to 
seek  a  method  which  at  least  might  be  applicable  to  such  cases  destined  for 
excision  of  the  large  intestine  as  had  previously  been  provided  with  a  colos- 
tomy. Doctor  Holman  and  I  found  that  dogs  tolerated  quite  well  what  we 
believed  to  be  a  complete  obstruction  of  the  descending  colon  for  four  days 
or  more,  the  time  apparently  required,  as  a  rule,  for  the  disintegration  of 
the  catgut  (No.  0  doubled)  purse-string  ligatures  with  which  the  abutted 
blind  ends  had  been  closed.6 

3  W.  S.  Halsted  and  Emile  Holman :  An  End-to-end  Anastomosis  of  the  Large  In- 
testine by  Abutting  Closed  Ends  and  Puncturing  the  Double  Diaphragm  with  an 
Instrument  Passed  Per  Rectum.  Johns  Hopkins  Hosp.  Bull.,  1921,  vol.  xxxii,  p.  98. 

4  W.  S.  Halsted :  A  Bulkhead  Suture  of  the  Intestine.  Jour.  Exp.  Med.,  1912,  vol. 
xv,  p.  216. 

Ernest  G.  Grey:  Studies  on  the  Aseptic  End-to-end  Anastomosis  of  the  Intestine. 
Johns  Hopkins  Hosp.  Bull.,  1918,  vol.  xxix,  p.  267. 

1  Willis  D.  Gatch :  Aseptic  Intestinal  Anastomosis.  An  Experimental  Study.  Journ. 
A.  M.  A.,  1912,  vol.  lix,  p.  185. 

8  Unsterilized  or  "  raw  "  catgut  seemed  to  dissolve  more  quickly  than  the  sterilized, 
but  it  was  not  so  strong,  and  Nos.  1  and  0  would  frequently  break  on  the  tying  of 
the  purse-strings. 


ASEPTIC  INTESTINAL  ANASTOMOSIS  251 

Soon  after  making  our  report  it  occurred  to  me  to  test  the  feasibility 
of  dividing  the  purse-string  ligatures,  or  at  least  of  puncturing  the  double 
diaphragm  by  a  protected  cautery  wire,  or  knife,  or  knives  passed  from 
below — per  rectum.  The  cautery  was  soon  abandoned,  being  considered  dan- 
gerous and  too  complicated.  The  knives — at  first  one,  later  three,  and  finally 
four — housed  in  a  short  cylinder  of  wood  or  metal  were  tested.  I  believed  in 
the  beginning  that  the  cylinder  should  approximately  fill  the  bowel  in  order 
to  centre  the  knife  and  thus  insure  the  cutting  of  the  purse-strings,  but  soon 
found  that  these  cylinders  might  actually  prevent  the  centering  of  the  knives 
unless  the  stitches  were  precisely  equidistant  from  the  centre. 

One  knife  proved  to  be  better  than  three  or  four  because  (1)  less  force 
was  required  to  cut  the  ligatures  or  perforate  the  diaphragms,  and  (2)  one 
of  the  three  or  four  knives  (blades  parallel  and  both  edges  of  each  knife 
sharpened)  might  engage  the  mucosa  of  the  intestinal  wall  at  the  margin 
of  or  just  below  the  inturn. 

The  Method. — The  vessels  supplying  the  portion  to  be  excised  are  occluded 
by  fine  transfixion  ligatures  carried  by  milliner's  needles,  and  are  divided  as 
shown  in  Plate  XV,  1.  Strong  Kocher  clamps  are  applied,  one  at  the  distal, 
the  other  at  the  proximal  end  of  the  piece  deprived  of  its  circulation.  Along 
the  proximal  edge  of  the  mark  made  by  the  proximal  clamp,  and  along  the 
distal  edge  of  the  mark  of  the  distal  clamp,  a  finely  basted  purse-string  stitch 
of  silk  7  is  run  with  a  milliner's  needle ;  these  ligatures  are  drawn  home  and 
only  a  half  knot  taken  in  each;  the  knots  are  completed  at  the  moment  the 
intestine  has  been  divided  with  the  electric  cautery  wire.  Prior  to  the  burn- 
ing, stout  threads  are  tied  about  the  isolated  segment  at  a  suitable  distance 
from  the  basting  stitches  (Plate  XV,  2).  The  purse-strings  can  be  drawn 
tighter  after  the  tension  caused  by  the  encircling  threads  has  been  relieved 
by  the  severance  of  the  gut.  After  the  burning,  the  little  overhangs,  which 
may  at  the  discretion  of  the  operator  be  further  sterilized  chemically  or  by 
the  electric  wire,  are  trimmed  with  scissors  as  close  as  feasible  to  the  purse- 
strings.  It  is  hardly  possible  to  cut  these  threads  in  the  trimming  process, 
and  hence,  without  fear,  one  snips  the  little  teat  of  everted  bowel  wall  com- 
pletely away  (Plate  XVII,  1). 

For  the  suturing,  a  single  row  of  mattress  stitches  suffices.  The  first  five 
of  these  (stay  stitches),  drawn  home  and  tied,  facilitate  the  introduction 
of  the  others  and  serve  as  guides  to  their  proper  placement.  The  order  in 
which  the  stitches  have  usually  been  taken  is  shown  in  Plate  XVII,  2,  and 
Plate  XVIII,  1  and  2.  The  two  at  the  mesenteric  border  are  placed  a  little 
closer  to  each  other  (Plate  XVIII,  1,  insert)  than  the  remainder,  and  are 
the  first  to  be  tied. 

'  Silk  was  used  for  the  purse-strings  to  exclude  the  possibility  of  misinterpretation 
of  the  results.  Were  the  purse-string  ligatures  of  catgut  one  could  not  be  sure  that 
the  restoration  of  the  bowel's  patency  was  due  to  the  cuting  of  these  ligatures  and 
not  to  their  dissolution. 


252  ASEPTIC  INTESTINAL  ANASTOMOSIS 

The  suturing  having  been  completed,  the  dog  is  drawn  down  until  his 
buttocks  overlap  the  edge  of  the  operating  table.  An  assistant  then  intro- 
duces per  rectum  the  instrument  with  which  the  purse-strings  are  to  be  cut. 
Plate  XIX,  2  and  3,  and  Plate  XX,  1  and  2,  depict  the  manoeuvres  so  well 
that  explanatory  notes  are  hardly  necessary.  The  purpose  of  the  short  piece 
of  rubber  tubing  is  to  protect  the  sphincter  from  the  sharp  edges  of  the  knife 
and  to  facilitate  its  introduction  into  the  rectum.  This  tube  is  left  in  the 
position  shown  in  Plate  XIX,  2,  until  the  knife  has  been  withdrawn. 

The  knife  point,  protected  by  a  little  piece  of  cork  on  the  tip,  is  propelled 
to  the  required  distance  by  the  assistant  who  manipulates  the  flexible  metal 
tail  (gas  tubing)  of  the  instrument.  With  no  more,  or  rather  less,  pressure 
than  is  required  for  the  introduction  of  a  stomach  tube,  the  knife  will  glide 
along  the  dog's  bowel  to  the  ileocaecal  valve.  When  the  knife  reaches  a  point 
in  the  pelvis  easily  accessible  to  the  operator's  hand  it  may  be  guided  by 
him  through  the  remainder  of  its  course  to  the  double  diaphragm;  but  it 
rarely  needs  such  guidance.  The  slightest  obstacle  to  the  progress  of  the 
knife  is  detected  by  the  assistant  in  charge  of  its  trailer  or  tail.  The  cork 
having  been  removed  (Plate  XX,  1),  it  is  slid  down  the  bowel  and  out  of 
the  way  (Plate  XX,  2).  In  making  the  thrust  the  operator  grasps  the  metal 
tubing  quite  close  to  the  shank  of  the  blade  and  aims  for  the  centre  of  the 
diaphragm,  hoping  thus  to  cut  both  of  the  purse-strings  (Plate  XX,  2). 
Whether  these  happen  to  be  divided  or  not  would  seem,  judging  by  the 
results,  to  be  immaterial,  nevertheless  one  should  make  two  or  three  thrusts 
at  slightly  different  spots,  but  all  as  near  the  centre  as  possible,  in  the  en- 
deavor to  cut  these  ligatures.  The  more  experienced  the  operator  the  better 
he  can  sense  the  greater  resistance  to  the  point  of  the  knife  offered  by  the 
tissues  so  tightly  compressed  by  the  purse-strings.  As  a  precautionary  meas- 
ure a  tapered  bougie  is  passed  through  the  diaphragm  before  closure  of  the 
abdominal  wound  (Plate  XX,  3). 

Forty-seven  dogs  have  been  operated  upon  by  this  method  without  a 
fatality  and  without  symptoms  indicative  of  an  abnormal  convalescence. 
The  bowel  resected  was  in  every  instance  the  colon.  The  operations  were 
performed  by  my  former  and  present  assistants  and  myself,  some  of  them 
by  recent  graduates  of  our  school  without  operative  surgical  experience. 
The  initial  experiments  were  made  with  an  extemporized  instrument — 
a  knife  housed  in  wood  and  mounted  on  a  brass  rod.  From  the  outset,  how- 
ever, it  was  our  intention  to  have  a  flexible  trailer  in  case  the  results  with 
our  crude  apparatus  seemed  promising.  Notwithstanding  the  defects  of 
the  unwieldy  home-made  instruments  used  in  the  earlier  experiments  and 
the  lack  of  experience  of  several  of  the  operators,  not  a  single  death  occurred. 

Hardly  a  year  had  passed  since  1886  when  with  the  assistance  of 
Dr.  Franklin  P.  Mall  I  made  many  experiments  in  intestinal  suture,"  with- 

h  W.  S.  Halsted :  Circular  Suture  of  the  Intestine — an  Experimental  Study.  Amer. 
Jour.  Med.  Sci.,  Phila.,  1887,  n.s.  No.  188,  p.  436. 

F.  P.  Mall :  Healing  of  Intestinal  Sutures.  Johns  Hopkins  Hospital  Reports,  Balti- 
more, 1896,  vol.  i,  p.  76. 


PLATE  XV 


1. — Ligation  of  the  Blood-Vessels  by  Transfixi 


2.— The  Marks  Made  by  the  Crush  of  the  Clamp  Serve  Merely  to 
Guide  the  Placing  of  the  Finely  Basted  Purse-Strings. 


PLATE  XVI 


1. — Purse-Strings   Tied   With   Half  Knots;   Stout    Ligatures   on   the 
Piece  to  be  Resected. 


2.— After  Division  of  the  Bowel  With  the  Cautery  the  Purse-Strings 
Are  Tightened  and  Their  Knots  Completed. 


PLATE  XVII 


1. — -The  Overhang  May  be  Trimmed  as  Close  as  Possible  Without 
Fear  of  Cutting  the  Purse-Strings. 


2.— The  First  of  the  Mattress  Stitches,  One  on  Each  Side  of  the 
Mesenteric  Border. 


PLATE  XVIII 


\ 


!  5 


1. — The   Five   Stay   Stitches;    the   Numerals   Indicate   the   Order   in 
Which   They  Are  Taken. 


2. — Traction   on   tin    Stay   Stitchea    Facilil  raking   of   the 


PLATE  XIX 


1. — Suture  Completed. 


2. — The  Knife  in  Transit  Through  the  Rubber  Tube  Which  Protects 
The  Sphincter. 


3. — The    Knife    Has   Been    Pushed    Up   to   the    Diaphragm    by    the 
Outside  Assistant. 


PLATE  XX 


1 —Removal  of  the  Cork. 


Corktip 


.-The  Cork  Pressed  Downward,  and  the  Purse-Strings  Divided. 


,;     Bougie  Passed  for  Control. 


ASEPTIC  INTESTINAL  ANASTOMOSIS  253 

out  further  experimental  investigation  of  this  subject  on  the  part  of  my 
assistants  and  myself.  Not  one  of  us  (Gatch,  Grey,  Holman,  Halsted)  had 
a  series  of  more  than  twenty-three  dogs  without  a  death.  The  present  series, 
therefore,  of  forty-seven  consecutive  successes  being  the  longest  for  our 
laboratory  and,  so  far  as  I  know,  hitherto  unequalled  elsewhere,  it  would 
seem  worth  while  to  offer  it  to  the  profession  for  trial  and  criticism. 

It  will  readily  be  conceded  for  this  method  that  the  amount  of  soiling 
could  hardly  be  less ;  it  is  little  more  than  occurs  in  a  simple,  properly  per- 
formed appendectomy. 

For  the  first  time,  therefore,  in  the  history  of  intestinal  suture  two  of  the 
factors,  the  soiling  and  the  amount  of  inturn,  have  been  reduced  almost  to  a 
constant,  and  hence  we  are  now  better  prepared  to  test  on  animals  the  relative 
merits  of  the  various  stitches  in  common  use. 

In  operations  on  the  human  intestine  the  surgeon's  only  criterion  has 
been  the  mortality ;  for  one  cannot  explore  the  abdomen  of  his  patient  every 
few  hours  after  operation  in  order  to  determine  the  amount  of  reaction 
(infection  and  adhesions)  about  the  line  of  suture,  the  fate  of  the  stitches, 
the  depth  of  the  inturn,  the  delay  in  its  unfolding,  etc. 

Unembarrassed  by  soiling,  or  eversion  of  the  mucous  membrane,  or  the 
presence  of  a  single  clamp  or  other  instrument,  or  by  the  fear  that  the  mesen- 
teric border  may  be  imperfectly  inverted,  or  that  the  amount  turned  in  may 
be  too  great  or  too  little,  or  that  some  point  of  a  running  stitch  may  have 
been  too  loose  or  too  tight,  the  operator  proceeds  in  orderly  and  uniform 
manner  from  the  beginning  to  the  end  of  the  performance. 

In  addition  to  the  two  constant  factors  mentioned  above — the  amount  of 
soiling  and  the  amount  turned  in — it  is  possible,  at  least  in  experiments  upon 
the  dog,  to  have  another  constant  factor,  viz.,  the  depth  to  which  the  stitches 
penetrate.  One  may  learn  in  a  few  minutes  to  sense  the  submucosa  with  the 
point  of  the  needle  and  to  include  a  part  of  it  in  the  stitch  without  entering 
the  lumen  of  the  gut.  With  a  little  practice  one  learns  not  only  to  pick  up  a 
thread  of  the  submucosa  but  to  press  the  needle  along  in  the  plane  of  this 
coat.  The  resistance  in  the  latter  case  may  be  so  great  as  to  remind  one  of 
that  experienced  in  the  taking  of  subcuticular  stitches.  Members  of  our 
upper  surgical  staff  can  all  testify  to  the  accuracy  of  this  statement.  And 
who  will  not  assent  to  the  view  that  it  is  desirable  to  take  the  submucous 
stitch  when  this  is  feasible  ?  Experience  has  taught  us  that  stitches  which  do 
not  enter  the  mucous  coat  become  ultimately  subperitonaeal  loops,  and  long 
before  the  diaphragm  or  flange  has  unfolded.  Uninfected,  they  are  cast 
outwards,  and  not  discharged  into  the  bowel's  lumen;  whereas,  the  per- 
forating stitches  seem  usually  to  ulcerate  their  way  into  the  gut.  We  some- 
times find  one  or  more  of  these  perforating  stitches  hanging  in  or  near  the 


254  ASEPTIC  INTESTINAL  ANASTOMOSIS 

line  of  suture  even  when  the  unfolding  process  is  about  complete — when 
little  trace  of  the  diaphragm  remains.  In  the  track  of  all  of  these  stitches 
which  are  discharged  into  the  bowel  there  has  necessarily  been  an  infected 
sinus  from  the  moment  of  their  placement  until  their  release.  Dr.  Florence 
Sabin,9  in  her  elaborate  and  unique  study  of  the  healing  of  Doctor  Holman's 
end-to-end  anastomoses  of  the  intestine,  rarely  found  that  a  stitch  had  per- 
forated: when  this  had  occurred  in  ever  so  slight  degree  there  was  inflam- 
matory reaction,  sometimes  a  small  abscess,  about  the  silk  thread. 

Sutures  falling  into  the  lumen  of  the  bowel,  being  quickly  transported,  are 
lost ;  only  such  are  discoverable  as  happen  still  to  be  attached  to  the  intes- 
tinal wall  when  the  animal  is  sacrificed.  Those  discarded  on  the  peritonaeal 
surface  may  remain  for  several  years  and  be  distinctly  seen  shimmering 
under  an  endothelial  film.  The  more  perfect  the  operation  the  fewer  the 
adhesions,  and  frequently  one  finds  even-  one  of  the  loops  outside  if  the 
mattress  stitches  have  been  happily  made.  Undoubtedly  in  the  hands  of 
novices  most  of  the  stitches  penetrate  the  mucosa ;  nevertheless  many  of 
these  perforating  mattress  stitches  cut  their  way  outwards ;  when  they  have 
pulled  through  the  mucosa,  the  fistulous  tract  becomes  sealed  from  within 
and  the  suture's  passage  towards  the  peritonaeum  may  thereafter  be  a 
clean  one. 

The  slogan  "  knots  inside  "  naturally  makes  an  appeal,  for  it  seems  uni- 
versally to  be  taken  for  granted  that  the  threads  necessarily  work  their 
way  into  the  lumen.  Year  after  year  for  thirty-five  years  I  have  had  oppor- 
tunities to  convince  myself  of  the  fact  that  in  the  cases  which  heal  most 
ideally  the  stitches  come  to  the  peritonaeal  surface.  The  omental  adhesions 
to  the  line  of  suture  in  such  cases  are  very  light  (occasionally  they  are 
absent)  and  in  a  few  weeks,  in  a  few  days  even,  may  be  absorbed  and  have 
left  no  trace. 

Consulting  the  original  paper  of  Lembert,"  I  was  interested  to  find  that 
his  stitches  were  cast  off  into  the  bowel.  He  states  this  definitely  and  makes 
no  mention  of  having  ever  seen  at  autopsy  a  loop  of  thread  shimmering  under 
the  peritonaeum.  This  fact  of  itself  suffices  to  prove  that  his  stitches,  con- 
trary to  the  universal  belief,  were  perforating  ones.  But  we  do  not  require 
this  particular  proof,  for  he  distinctly  states  that  he  intentionally  entered 
the  lumen  of  the  intestine  with  his  needle,  except  when  the  wall  was  thick ; 

'Florence  R.  Sabin:  Healing  of  End-to-end  Intestinal  Anastomoses  with  Special 
Reference  to  the  Regeneration  of  Blood-Vessels.  Johns  Hopkins  Hosp.  Bull.,  1920, 
vol.  xxxi.  p.  2S9. 

"  A.  Lenibert :  Memoire  sur  Tenteroraphie,  avec  la  description  d'un  procede  nouveau 
pour  pratiquer  cette  operation  chirurgicale.  Repertoire  gen.  d'anat.  et  de  physiologie 
pathologiques,  etc.   Paris,  1S26,  vol.  ii,  p.  100. 


ASEPTIC  IXTESTIXAL  ANASTOMOSIS  255 

and  in  this  event  the  needle  glided  B  between  the  coats.  Xow  it  is  question- 
able, I  think,  that  even  in  the  thick -walled  cases  he  slid  the  needle  between 
the  coats  without  entering  the  intestinal  lumen.  He  apparently  knew  noth- 
ing of  the  existence  of  the  submucosa,  and  his  needle,  if  it  "  glided,"  must 
have  passed  on  one  side  or  the  other  of  this  coat — either  between  the  mus- 
cular and  submucous  coats,  or  between  the  latter  and  the  mucosa ;  it  would 
not  glide  along  in  the  tough  submucous  coat.  If  the  stitches  had  included 
only  the  peritonaeal  and  muscular  coats  they  would  have  split  the  longitudi- 
nal fibres,  have  constricted  or  crushed  the  circular  ones  and  at  best  have  had 
an  insecure  hold ;  and  if  they  had  perforated  the  submucosa  they  undoubtedly 
entered  the  intestine's  lumen.  Thus,  in  all  probability,  Lembert's  stitches 
quite  invariably  entered  the  lumen,  whatever  the  thickness  of  the  bowel's 
wall ;  and,  in  any  event,  Lembert  intentionally  perforated  the  wall  unless  it 
was  thick.  Hence  the  Lembert  stitch  has  been  universally  misunderstood, 
and  the  erroneous  description  of  some  early  author  has  been  passed  on  from 
one  writer  to  another  until  the  present  time.  Picture  the  amount  of  soiling 
there  must  have  been  in  Lembert's  experiments.  In  placing  his  stitches  he 
introduced  a  finger  into  the  bowel,  using  it  as  a  guide,  as  a  darning  ball." 
Furthermore,  the  stitches  perforated  the  intestinal  wall  and  were  discharged 
into  the  lumen.  Nevertheless  the  five  dogs  upon  whom  he  operated  all 
recovered. 

In  the  entire  literature  of  intestinal  suture  there  are,  perhaps,  no  more 
impressive  examples  of  nature's  ability  to  protect  against  man's  faulty  opera- 
tive methods  than  those  furnished  by  Merrem's  u  resections  of  the  pylorus 
(1809  and  1810). 

Merrem  excised  the  pylorus  in  three  dogs — two  in  1809  and  one  in  1810. 
In  the  first  dog,  attempts  at  invagination  being  unsuccessful,  the  raw  edges 
of  the  stomach  and  duodenum  were  apposed  and  held  by  only  three  stitches. 

"A.  Lembert,  I.e.,  p.  105:  "  L 'aiguille  penetre  a  2  lignes  environ  du  bord  saignant 
droit,  dans  la  cavite  de  l'intestin,  ou  bien  sa  pointe  glisse  entre  les  tuniques  mus- 
culeuse  et  muqueuse,  suivant  que  l'intestin  est  plus  ou  moins  epais." 

"Lembert,  I.e.,  p.  106:  "  Le  chirurgien,  .  .  .  porte  l'index  de  la  main  gauche  dans 
la  cavite  de  l'intestin,  de  maniere  a  soutenir  les  bords  saignans  avec  la  pulpe  de 
ce  doigt." 

"  Merrem 's  paper  (Animadversiones  quaedam  chirurgicae  experiments  in  animalibus 
factis  illustratae.  Giessae,  1810)  is  listed  in  the  Index  Catalogue  of  the  Surgeon  Gen- 
eral's Library,  but  could  not  be  located.  Therefore  I  wrote  to  Professor  Payr,  who, 
unable  to  find  it  in  Leipzig,  kindry  sent  me  Carl  Langenbeck's  abstract  (Abschrift 
eines  R,eferates  von  C.  J.  M.  Langenbeck,  Professor  der  Anatomie  und  Chirurgie, 
Direktor  des  chirurgischen  Spitals  in  Gbttingen,  aus  Bibliothek  fur  die  Chirurgie,  4. 
Band  1.  Stuck.  Gbttingen.  Rudolph  Deuerlich,  1811).  I  appealed  also  to  Prof.  Felix 
Landois,  of  Berlin,  who  found  Men-em's  paper  and  sent  me  quotations  from  it  which 
he  had  graciously  translated  into  German. 


256  ASEPTIC  INTESTINAL  ANASTOMOSIS 

Death  occurred  on  the  twenty -third  day  from  "  inanition  " ;  there  was  no 
peritonitis,  and  the  suture-line  was  so  well  healed  that  no  trace  of  it 
remained. 

In  the  second  and  third  dogs  the  stomach  was  invaginated  into  the  duode- 
num— serosa  apposed  to  mucosa.  The  second  dog  recovered ;  the  third  died. 
In  all  of  the  experiments  the  threads  of  the  gastro-enterorrhaphy  were 
brought  out  of  the  abdominal  wound  and  fastened  to  the  surface  with  ad- 
hesive plaster.  The  severed  pyloric  artery  could  not  be  tied  on  account  of 
its  depth ;  the  haemorrhage  was  checked  with  sponge  and  spirits. 

Let  those  of  us  who  are  inclined  to  be  content  with  our  present  methods 
of  end-to-end  anastomosis  bear  in  mind  these  experiments  of  Merrem  and 
of  many  other  early  research  workers  and  observe  on  animals  the  early 
stages  of  repair  of  our  own  intestinal  sutures,  to  the  end  that  we  may  under- 
stand the  part  that  nature  plays  to  protect  the  patient  from  the  crudity  of 
our  handiwork. 

Notwithstanding  much  experimentation,  we  have  been  unable  to  improve 
upon  the  method  developed  thirty-five  years  ago,14  unless  perhaps  the  pro- 
cedure submitted  in  this  communication  shall  prove  to  be  an  advance.  We 
have  at  least  learned  in  recent  years  that  it  is  safe,  and  probably  advisable, 
to  make  a  deeper  inturn,  and  have  devised  a  cleaner  procedure.  It  remains 
to  be  determined  whether  in  the  blind-end  method  the  continuous  suture 
will  yield  results  as  good  as  those  we  have  obtained  by  the  mattress  stitches. 
Better  they  can  hardly  be. 

For  lateral  anastomosis  the  mattress  stitches  possess  the  advantage  that 
they  can  all  be  taken  before  the  bowel  is  opened,  that  one  row  of  them  suffices, 
and  that  infection  of  one  stitch  is  unlikely  to  be  conveyed  to  the  others. 

As  stated  earlier  in  the  paper,  it  is  not  known  how  deep  the  inturn  should 
be.  It  may  safely  be  assumed,  however,  that  the  deeper  the  inturn  the 
better,  provided  obstruction  is  not  produced  by  it.  Granting  this,  how  many 
rows  of  suture  should  be  made?  Fortunately  the  apposed  serous  surfaces 
of  the  diaphragm  tend  to  remain  firmly  in  contact.  That  the  process  of 
unfolding  begins  promptly  we  know  from  the  rapid  cutting  outwards  of  the 
properly  placed  sutures  as  well  as  from  early  observations  on  the  mucous 
side;  and  from  this  continuous  effort  to  unfold  we  infer  the  force  maintain- 
ing the  peritonaeal  surfaces  in  contact  from  the  line  of  suture  to  the  raw 
edges.  Every  stitch,  whether  essential  or  superfluous,  interferes  more  or  less 
with  the  circulation,  hence  the  necessity  for  eliminating  any  that  may  be 
unnecessary.   In  circular  suture  of  the  intestines  of  a  variety  other  than  the 

M  W.  S.  Halsted:  Circular  Suture  of  the  Intestine — an  Experimental  Study.  Amer. 
Jour.  Med.  Sci..  Philadelphia,  1887,  n.s.,  vol.  xciv,  p.  436. 


ASEPTIC  INTESTINAL  ANASTOMOSIS  257 

blind-end  we  have  advocated  (1887,  loc.  cit.)  a  few  presection  stitches,  taken 
chiefly  with  the  purpose  of  preventing  the  outward  rolling  of  the  bowel  wall 
and  thus  facilitating  the  introduction  of  the  mattress  row. 

If  we  bear  in  mind  that  every  perforating  stitch  is  a  source  of  danger, 
however  slight,  as  well  as  a  menace  to  the  circulation,  our  efforts  will  be 
directed  towards  the  suppression  of  unnecessary  stitches  and  the  cultivation 
of  the  sense  which  makes  possible  the  appreciation  with  the  needle's  point  of 
the  resistance  offered  by  the  submucosa.  That  in  resection  of  the  human 
colon  one  row  of  mattress  stitches  is  better  than  two,  I  am  not  as  yet  prepared 
to  affirm,  but  in  the  dog  it  has  given  results  in  the  blind-end  suture  so  per- 
fect that  I  should  regard  a  second  row  as  a  factor  of  danger  rather  than 
security. 

The  more  perfect  the  execution  of  any  method  of  end-to-end  anastomosis, 
the  less  reaction  about  the  line  of  suture  and  the  greater  the  rapidity  of  the 
unfolding  of  the  inturn,  of  the  complete  restoration  of  the  lumen  of  the 
bowel.  In  one  of  our  specimens,  for  example,  little  remained  of  the  dia- 
phragm on  the  tenth  day ;  in  another  there  was  no  trace  of  it  on  the  seven- 
teenth day.  On  the  other  hand,  the  inturn  in  one  case  was  about  as  deep  on 
the  109th  day  as  at  the  beginning.  An  exceptionally  bad  result  in  this  case 
(an  early  one)  was  predicted  because  the  force  required  to  puncture  the 
diaphragms  with  the  three  broad  knives  was  so  great  that  the  stitches  (per- 
forating ones)  tore  little  streaks  in  the  bowel  walls.  The  operation  was 
cleverly  performed  by  an  eminent  European  surgeon  who  had  not  practised 
the  submucous  stitch.  The  animal's  recovery  and  normal  convalescence  were 
surprising;  at  no  time  in  the  109  days  after  operation  were  there  symptoms 
of  obstruction.  It  will  readily  be  understood  that  great  reaction,  causing 
matting  of  the  omentum  and  intestines  about  the  line  of  suture,  may  lead 
to  the  formation  of  fibrous  tissue  in  the  infiltrated  intestinal  wall  so  dense 
and  so  extensive  as  to  delay  for  a  long  time,  and  possibly  permanently  pre- 
vent the  complete  unfolding  of  the  inturn.  The  surgeon  should  bear  in 
mind  this  fact,  unemphasized  perhaps  hitherto,  and  the  experimenter  in 
testing  the  relative  merits  of  the  various  procedures  for  lateral  as  well  as 
end-to-end  anastomosis  should  note  the  rapidity  of  the  unfolding  and  accept 
the  tardy  disappearance  of  the  flange  as  evidence  of  a  faulty  technic  either 
of  method  or  execution  or  both. 

The  opportunity  has  not  as  yet  presented  at  The  Johns  Hopkins  Hospital 
to  perform  the  blind-end  suture  on  the  human  subject.  We  shall  probably 
test  it  first  on  cases  in  which  a  lateral  anastomosis  is  not  feasible.  The 
knife  passes  readily  to  the  ileocaecal  valve  in  the  dog,  and  in  one  instance 
Doctor  Holman,  after  resecting  the  caecum,  abutted  the  closed  ends  of  ileum 
and  ascending  colon  and  cut  the  diaphragms  with  the  knife;  the  dog  re- 
18 


258  ASEPTIC  INTESTINAL  ANASTOMOSIS 

covered  normally.  "When  the  splenic  flexure  is  hooked  high  ( Parr's  Doppel- 
flinte)  it  might  be  difficult  without  mobilizing  to  traverse  it  with  the  knife. 
But  for  resections  of  the  descending  colon,  of  the  sigmoid  flexure,  of  the 
rectum  when  the  sphincter  is  to  be  preserved,  and  possibly  of  the  gastric  end 
of  the  oesophagus,  the  method  deserves,  I  believe,  a  trial. 

I  am  greatly  indebted  to  Dr.  F.  L.  Eeichert  and  to  Dr.  Emile  Holman 
for  assistance  in  every  phase  of  the  work.  Dr.  Mont  Eeid  also  has  most 
kindly  aided  me  in  many  ways.  A  detailed  report  of  the  experiments  will 
be  made  later  bv  Doctor  Eeichert  and  Doctor  Holman. 


THE  OPERATIVE  TREATMENT  OF 
INGUINAL  HERNIA 


THE  E ADICAL  CUEE  OF  HEENIA  ■ 

Dr.  William  S.  Halsted  presented  five  patients  *  upon  whom  he  had  per- 
formed his  operation  for  the  cure  of  inguinal  hernia.  He  described  the 
operation  as  follows : 

1.  The  incision  begins  at  the  external  abdominal  ring,  and  ends  one  inch 
or  less  (less  than  one  inch  in  children)  to  the  inner  side  of  the  anterior 
superior  spine  of  the  ilium  on  an  imaginary  line  connecting  the  anterior 
superior  spines  of  the  ilia.  Throughout  the  entire  length  of  the  incision 
everything  superficial  to  the  peritonaeum  is  cut  through. 

2.  The  vas  deferens,  with  its  vessels,  is  carefully  isolated  up  to  the  outer 
termination  of  the  incision,  and  held  aside. 

3.  The  sac  is  opened  and  dissected  from  the  tissues  which  envelop  it. 

4.  The  abdominal  cavity  is  closed  by  quilted  sutures  passed  through  the 
peritonaeum  at  a  level  higher  by  1^-2  inches  than  that  of  the  so-called  neck 
of  the  sac. 

5.  The  vas  deferens  and  its  vessels  are  transplanted  to  the  upper  outer 
angle  of  the  wound. 

6.  Interrupted,  strong  silk  sutures,  passed  so  as  to  include  everything 
between  the  skin  and  the  peritonaeum,  are  used  to  close  the  deeper  portion 
of  the  wound,  which  is  sewed  from  the  crest  of  the  pubes  to  the  upper  outer 
angle  of  the  incision.  The  cord  now  lies  superficial  to  these  sutures,  and 
emerges  through  the  abdominal  muscles  about  one  inch  to  the  inner  side  of 
the  anterior  superior  spine  of  the  ilium. 

7.  The  skin  is  united  over  the  cord  by  interrupted  stitches  of  very  fine  silk. 
These  stitches  do  not  penetrate  the  skin,  and  when  tied  they  become  buried. 
They  are  taken  from  the  under  side  of  the  skin,  and  made  to  include  only 
its  deep  layers — the  layers  which  are  not  occupied  by  sebaceous  follicles. 

Dr.  Halsted  has  for  more  than  two  years  sewed  most  of  his  wounds  in  this 
way.  The  method  was  suggested  to  him  from  his  experiments  on  dogs.  He 
thinks  that  it  is  very  difficult,  and  perhaps  impossible,  to  disinfect  the  skin 
of  a  dog,  and  believes  that  pyogenic  organisms  may  occasionally  be  present 
in  the  sebaceous  follicles  of  the  skin.  At  any  rate,  he  had  repeatedly  observed 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society.  Baltimore,  Novem- 
ber 4,  1889. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1890.  i,  12-13. 

2  First  operations  for  hernia,  W.  S.  H. 

261 


262  RADICAL  CUEE  OF  HEENIA 

pus  in  the  suture  holes  of  the  perforating  skin  stitches,  and  could  not  with 
any  certainty  secure  primary  union  of  the  skin  wounds  of  dogs  until  he  had 
resorted  to  this  subcutaneous  method  of  sewing  the  skin. 

Dr.  Halsted  remarked  in  this  connection  that  whether  or  not  it  were 
possible  or  easy  to  disinfect  absolutely  the  human  skin,  he  had  been  much 
impressed  with  the  fact  that  skin  sutures  not  infrequently  suppurate,  even  in 
wounds  sewed  by  the  most  careful  surgeons  in  this  country  and  abroad.  He 
thought  it  advisable,  therefore,  to  test  for  a  time  the  subcutaneous,  buried, 
skin  suture. 

8.  One  or  two  small,  short  gauze  plugs  are  used  as  wound  drains. 

The  After  Treatment. — The  gauze  plugs  are  removed  at  the  first  subse- 
quent dressing — usually  at  about  the  seventh  day.  The  patients  are  allowed 
to  walk  about  on  the  21st  day. 

The  following  is  a  brief  summary  of  the  cases :  * 

Case  1. — Wm.  H.  Eichardson,  colored,  age  8  years.  Operation,  June  13, 
1889,  for  the  cure  of  large  congenital  inguinal  hernia  on  the  right  side.  The 
sac  when  opened  contained  caecum  and  vermiform  appendix — a  very  short 
mesocaecum  bound  the  sac  to  its  contents. 

June  2d. — The  wound  has  healed  by  first  intention,  except  where  the 
gauze  plug  was  introduced.  Linear  cicatrix. 

July  4th. — Patient  is  allowed  to  get  up  and  walk  about. 

Case  2. — George  Holdorf,  German,  blacksmith,  age  20.  Operation, 
June  17,  1889,  for  the  cure  of  a  moderately  large,  reducible,  right  inguinal 
hernia. 

June  ISth. — Gauze  plug  removed. 

June  25th. — Patient  is  discharged  for  misdemeanor.  "Wound  has  healed 
by  first  intention.  Linear  cicatrix. 

Case  3. — John  Bleecher,  German,  blacksmith,  age  48.  Operation, 
August  16,  1889,  for  the  cure  of  a  large,  reducible,  right  inguinal  hernia. 
The  neck  of  the  sac  was  large  enough  to  admit  the  tips  of  four  fingers. 

August  26th. — Passes  urine  through  wound.  Infer  that  one  of  the  deep 
sutures  was  passed  through  the  wall  of  the  bladder. 

September  J^th. — Patient  passes  all  of  his  urine  through  the  penis. 

September  17th. — Patient  is  out  of  bed.  The  wound  is  healed  except  at 
its  lower  angle. 

I  iSB  4. — Joseph  Davis,  age  8  years.  Operation,  October  9,  1889,  for  the 
cure  of  a  small,  reducible,  left  inguinal  hernia. 

October  19th. — Wound  has  healed  by  first  intention.   Linear  cicatrix. 
November  3d. — Boy  is  allowed  to  get  up  and  walk  about. 

—Frank  Fisher,  age  ?  years.    Operation,  October  12th,  for  the 
cure  of  a  small,  right  inguinal  hernia. 

October  20th. — Wound  has  healed  by  first  intention.   Linear  cicatrix. 
November  J,th. — Boy  is  allowed  to  get  up  and  walk  about. 


THE  RADICAL  CURE  OF  HERNIA ' 

The  patient  is  one  who  was  operated  upon  three  weeks  ago  for  the  radical 
cure  of  an  inguinal  hernia.  The  celloidin  dressing  was  removed  as  usual 
on  the  third  day  and  the  wound  was  as  usual  perfectly  healed.  The  scar, 
you  will  observe,  is  scarcely  perceptible.  The  patient  is  exhibited  because 
he  has  a  complication — thrombosis  of  the  femoral  vein.  We  take  such  deep 
stitches  into  the  pillars  of  the  ring  that  I  am  not  surprised  at  this  compli- 
cation. In  one  case  we  passed  a  stitch  through  the  wall  of  the  bladder.  The 
patient,  however,  recovered. 

Thus  far  there  has  been  no  return  of  the  hernia  in  any  of  the  twelve  or 
more  patients  operated  upon  by  the  method  which  I  described  to  you  last 
year.  The  muscles  of  the  abdominal  wall  are  divided  out  to  the  level  of 
the  anterior  superior  spine  of  the  ilium.  The  walls  of  the  sac  are  sutured 
by  quilted  sutures  at  as  high  a  level  as  possible.  There  is,  of  course,  no  neck 
to  the  sac  after  the  abdominal  muscles  have  been  divided.  The  sac  is  cut 
away  and  the  vas  deferens,  with  its  vessels,  is  transplanted  to  the  outer  angle 
of  the  wound.  The  divided  muscles  and  the  pillars  of  the  ring  are  stitched 
with  very  deep  quilted  sutures.  It  is  sometimes  necessary  to  take  as  many 
as  eight  or  even  ten  of  these  sutures.  The  skin  wound  is  closed  by  buried 
skin  sutures.  A  small,  narrow  pad  of  sterilized  gauze,  placed  over  the  line 
of  the  incision,  is  held  in  place  by  two  or  three  turns  of  a  gauze  bandage 
which  has  been  soaked  in  absolute  alcohol.  Celloidin  is  then  poured  liberally 
over  the  little  dressing. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  October  20, 
1890. 
Johns  Hopkins  Hosp.  Bull.,  Bait,  1890,  i,  111-112. 


263 


EXCISION  OF  SOME  OF  THE  VEINS  OF  THE  CORD  IN  THE 

OPERATION  FOR  THE  RADICAL  CURE  OF 

INGUINAL  HERNIA a 

Dr.  Halsted  presented  several  cases  to  illustrate  a  modification  of  his 
operation  for  the  cure  of  hernia.  The  bundle  of  veins  which  accompanies 
the  vas  deferens  is  often  as  large  as  one's  finger.  He  believes  that  some  or 
most  of  these  veins  may  be  superfluous,  and,  accordingly,  excises  all  but 
one  or  two  of  them.  By  this  procedure  the  cord  may  often  be  reduced  to  less 
than  one-fourth  of  its  original  size.  It  is  reasonable  to  suppose  that  the 
size  of  the  cord  may  influence  the  tendency  of  the  hernia  to  return. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  January  18, 
1892. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1892,  iii,  76. 


264 


THE  RADICAL  CURE  OF  INGUINAL  HERNIA  IN  THE  MALE ' 

Shuh  said,  "  If  no  other  field  were  offered  to  the  surgeon  for  his  activity 
than  herniotomy,  it  would  be  worth  while  to  become  a  surgeon  and  to  devote 
an  entire  life  to  this  service."  Quite  as  well,  certainly,  might  this  be  said  of 
operations  for  the  radical  cure  of  hernia.  There  is,  perhaps,  no  operation 
which  has  had  so  much  of  vital  interest  to  both  physician  and  surgeon  as 
herniotomy,  and  there  is  no  operation  which,  by  the  profession  at  large, 
would  be  more  appreciated  than  a  perfectly  safe  and  sure  cure  for  rupture. 

Just  now,  most  of  the  so-called  radical-cure  operations  are  under  a  cloud. 
They  have  not  withstood  the  test  of  time.  Modern  textbooks  of  surgery 
refer  to  operations  for  the  radical  cure  of  hernia  with  more  or  less  mis- 
giving. The  newest  American  surgery 2  disapproves  of  operations  for  the 
radical  cure  of  reducible  hernia  if  a  truss  can  be  worn,  and  believes  that 
Czerny's  method  is  as  good  as  any,  should  an  operation  be  necessary. 

The  most  telling  blows  against  radical-cure  operations  in  this  country 
have  been  dealt,  perhaps,  by  Bull.  His  papers  on  the  radical  cure  of  hernia 
and  on  relapses  after  the  various  operations  for  the  radical  cure  of  hernia 
have  produced  a  profound  impression  on  both  practitioners  of  medicine  and 
practitioners  of  surgery.  Bull  concludes  the  first  of  these  papers  3  as  follows : 
"  These  observations  will,  without  doubt,  be  duplicated  in  the  cases  yet  to 
be  traced,  and  go  to  strengthen  the  conviction  that  all  methods  of  radical 
cure  will  be  found  unsatisfactory."  In  his  second  paper  *  he  writes :  "  I  hold, 
after  the  knowledge  of  these  failures  and  in  view  of  the  well-established 
fact  that  after  the  old  operations  for  hernia  recurrence  has  been  often  long 
delayed,  that  it  is  wise  to  drop  the  term  cure  and  to  estimate  the  value  of 
•  given  procedures  by  the  relative  proportion  of  relapses." 

From  1883  to  1885,  Bull  operated  for  the  cure  of  hernia  chiefly  by  what 
he  calls  Socin's  method — ligature  and  excision  of  the  sac.    From  1885  to 

1Read  at  the  Annual  Meeting  of  the  Medico-Chirurgical  Faculty  of  Maryland, 
Easton,  Maryland,  November  17,  1892. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1893,  iv,  17-24.   (Reprinted.) 
Also:  Ann.  Surg.,  Phila.,  1893,  xvii,  542-556. 

2  An  American  Textbook  of  Surgery.  Keen  and  White. 

3  Bull :  On  the  radical  cure  of  hernia,  with  results  of  one  hundred  and  thirty-four 
operations:    Medical  News,  1890. 

4  Bull :  Notes  on  cases  of  hernia  which  have  relapsed  after  various  operations  for 
radical  cure. 

265 


266  EADICAL  CUKE  OF  INGUINAL  HERNIA 

1889  he  employed  what  he  calls  Banks'  method — ligature  and  excision  of 
the  sac,  with  suture  of  the  pillars  of  the  external  ring.  Since  1889  he  has 
practised  the  sewing  up  of  the  canal  after  ligating  and  excising  the  sac. 

Of  the  cases  operated  upon  by  the  first  method,  at  least  27.27  per  cent 
relapsed  within  one  year;  of  those  operated  upon  by  the  second  method, 
at  least  40  per  cent  relapsed  within  one  year;  and  of  those  operated  upon 
by  the  third  method,  at  least  42  per  cent  relapsed  within  one  year. 

"  My  own  results,"  writes  Bull,  "  as  to  relapse  being  no  better  by  the 
complicated  method  of  suture  of  the  ring  alone,  or  of  the  ring  and  canal, 
than  by  the  simpler  method  of  excision  of  the  sac  after  ligature,  I  shall 
confine  myself  to  that  method  of  operation  till  other  procedures  which  have 
stood  the  test  of  years  make  a  more  promising  showing."  Bull's  results 
became  less  promising  the  longer  he  observed  his  cases.  From  a  series  of 
one  hundred  and  thirty-six  cases  there  remained  only  four  which  had  been 
over  four  years  without  recurrence.  In  his  second  paper  Bull  says :  "  Now 
that  ten  years  have  elapsed  since  the  modern  radical  operations  have  been 
in  vogue,  we  ought  to  hear  of,  or  have  presented  to  us,  patients  who  have 
been  more  than  five  years,  at  the  least,  without  relapse.  We  could  naturally 
expect  to  see  such  cases  occasionally  at  a  special  hospital.  But  there  are 
none  such."  Notwithstanding  these  facts,  Bull  does  not  advise  that  opera- 
tions for  the  relief  of  hernia  be  discontinued,  nor  does  he  wish  to  discon- 
tinue efforts  to  discover  more  satisfactory  methods  for  its  cure.  For,  of  the 
cases  operated  upon,  almost  all  were  relieved  for  a  time,  and  some  for  several 
years;  and  of  the  cases  which  had  relapsed,  the  majority  were  more  com- 
fortable than  they  had  been  before  they  were  operated  upon. 

These  are  admirable  papers  and  faithfully  depict  what  is  to  be  expected 
if  a  hernia  is  operated  upon  by  the  methods  which  Bull  has  employed. 
Today,  therefore,  the  majority  of  surgeons  operate  for  the  radical  cure  of 
hernia  only  when  the  hernia  is  strangulated  or  cannot  be  retained  with  a 
truss.  A  few  believe  that  they  have  had  results  good  enough  to  justify  their 
operations  upon  almost  every  case  which  presents  itself. 

Until  the  sixteenth  century  incarcerated  hernia  was  treated  only  by  taxis. 
If  taxis  failed,  the  patient  died.  An  ordinary  rupture  and  stone  cutter, 
Pierre  Franco,  was  the  first  to  relieve  incarceration  by  herniotomy.  As 
preeminent  among  his  fellows  as  Pare  was  among  surgeons,  he  is  one  of  the 
most  illustrious  figures  in  surgical  history.  He  has  described,  and  probably 
was  the  first  to  conceive  both  the  intraperitonaeal  and  extraperitonaeal  meth- 
ods of  herniotomy.  The  following  is  an  extract  from  his  chapter  on 
herniotomy : 8 

8  Lehrbuch  der  Chirurgie,  Bd.  iii.  Eduard  Albert. 


RADICAL  CURE  OF  INGUINAL  HERNIA  267 

"  When  all  other  means  have  failed  we  proceed  to  operate.  One  must  have 
a  little  staff  of  the  thickness  of  a  goose-quill,  or  somewhat  thicker,  and 
round,  on  one  side  flat  and  half  round  and  it  must  be  rounded  off  at  the 
front  end  that  one  may  press  forward  easier.  One  makes  accordingly  an 
incision  at  the  upper  part  of  the  scrotum,  drawing  towards  the  pubes,  and  at 
the  outset  makes  the  opening  only  just  large  enough  to  admit  the  staff,  for 
one  must  take  care  that  he  does  not  thrust  into  the  intestines.  When  one 
has  found  the  hernial  sac,  one  must  insinuate  the  little  staff  between  it  and 
the  groin  and  then  push  upwards.  The  flat  side  of  the  staff  must  be  up. 
It  would  not  succeed  if  the  staff  were  entirely  round  for  the  knife  would 
then  glide  from  side  to  side.  When  one  has  pushed  the  staff  far  enough,  he 
cuts  upon  the  flat  side  of  it  through  the  flesh  of  the  scrotum  and  groin  so 
as  not  to  injure  the  intestines  now  that  he  has  made  a  larger  opening ;  there 
is  no  danger  in  making  the  opening  large  enough  to  enable  one  to  replace 
the  intestines  the  more  easily  because  the  sac  and  the  flesh  of  the  belly  can 
then  be  the  more  readily  stretched,  and  hence  perhaps  the  intestines  be  re- 
turned the  more  nearly  into  their  correct  position.  One  must  reintroduce 
them  little  by  little.  Should  the  case  occur  that  they  will  not  go  back  easily 
and  without  great  pressure  because  of  too  great  an  accumulation  of  their 
contents  or  on  account  of  inflammation,  then  one  must  proceed  as  follows : 
one  takes  the  hernial  sac  and  cuts  it  very  delicately  upon  the  nail  while  one 
raises  the  sac  with  hooks  and  cuts  it  through  to  the  intestines :  and  when 
one  has  made  an  opening  large  enough  to  admit  the  staff  one  pushes  it  very 
gently  upwards  between  the  sac  and  the  intestines;  at  the  same  time  one 
must  push  the  parts  aside  so  as  to  see  if  he  is  catching  the  intestines.  The 
intestines,  however,  are  not  easily  caught  because  they  are  homogeneous  and 
smooth.  One  must  accordingly  divide  the  sac  upon  the  staff  up  to  the  peri- 
tonaeum, that  is,  up  to  the  highest  point,  namely,  to  the  hole  where  the  intes- 
tines begin  to  descend  to  the  scrotum;  but  one  must  make  a  generous 
opening  into  the  peritonaeum  without  fear  and  for  the  sake  of  greater  safety, 
just  as  one  does  in  desperate  cases  of  the  kind.  One  then  takes  a  little  piece 
of  fine  linen  and  pushes  the  intestines  gradually  back,  beginning  with  those 
which  are  higher  up  towards  the  peritonaeum  and  which  lie  nearer  to  the 
belly." 

The  suggestion  of  Franco  to  replace  the  intestines  with  linen  is  an  excel- 
lent one,  and  for  me  one  of  the  proofs  of  his  genius.  There  are  today  many 
surgeons  who  have  not  discovered  this  device  and  who  labor  with  the  fingers 
to  introduce  the  slippery  intestines.  With  a  piece  of  gauze  one  can  replace 
the  intestines  rapidly  and  with  precision,  whereas  the  manipulation  of  the 
intestines  with  the  fingers  is  often  a  ludicrous  performance.  Pare,  about 
the  middle  of  the  sixteenth  century,  gives  precise  instructions  for  perform- 
ing herniotomy.  He  was  probably  the  first  surgeon  to  prescribe  herniotomy 
for  all  cases  of  incarcerated  hernia.  But  it  was  not  until  the  end  of  the 
seventeenth  century  or  beginning  of  the  eighteenth  century  that  the  opera- 
tion, through  the  efforts  of  Wiseman,  Petit,  and  Richter,  became  generally 
recognized  and  practised. 


268  EADICAL  CUKE  OF  INGUINAL  HEENIA 

From  a  clinical,  anatomical  and  pathological  standpoint  the  work  of 
Sir  Astley  Cooper  on  hernia  is  undoubtedly  the  greatest  of  all,  and  very 
little  has  been  added  to  our  knowledge  of  hernia  of  all  kinds  since  his  book 
appeared.  From  his  chapter  on  the  operation  for  inguinal  hernia  one  gets  a 
good  idea  of  the  respect  which  surgeons  at  the  beginning  of  this  century  had 
for  arteries.  Speaking,  for  example,  of  the  division  of  the  little  external 
pubic  artery,  which  always  crosses  the  sac  near  the  external  abdominal  ring, 
he  says : 

"  This  circumstance,  however,  is  in  no  degree  alarming  to  a  surgeon  who 
expects  it,  as  the  bleeding  may  be  stopped  by  the  vessel  being  compressed  by 
an  assistant,  or  if  the  artery  is  larger  than  usual,  owing  to  the  scrotum  being 
long  distended  by  the  disease,  the  blood  may  be  stopped  by  a  ligature." 

Cooper  substituted  his  world-famed  herniotome  for  the  bulb-pointed  knife, 
and  abolished  the  use  of  the  hollow  director  which  the  disciples  of  Franco 
and  Pare  believed  to  be  indispensable. 

Otherwise  the  technique  of  herniotomy  is  today  precisely  that  of  Franco, 
the  gifted  stone  and  rupture  cutter  of  the  sixteenth  century,  except  that  in 
preaseptic  times  he,  perhaps  wisely,  preferred  the  extraperitonaeal  *  to  the 
intraperitonaeal  method.  The  actual  war  which  these  two  methods  stirred 
up  among  surgeons  for  more  than  a  century  is  interesting.  On  the  side  of 
Petit,  who  after  Franco  was  the  great  disseminator  and  defender  of  the 
method,  we  find  arrayed  from  the  English,  Cooper.  Key.  Teale,  Paget, 
Liston.  Gay.  Lawrence,  and  others ;  from  the  Germans,  Eoser.  Shuh,  Dum- 
mericher.  Busch,  Bauni,  and  others;  from  the  French,  Gosselieu,  Chauvet, 
Le  Dentu,  and  others. 

The  same  objections  and  the  same  refutations  appear  year  after  year. 
The  inconsistency  of  those  opposed  to  the  extraperitonaeal  method  is  remark- 
able. They  were,  for  example,  all  of  them  advocates  of  the  taxis,  and  would 
not  resort  to  the  cutting  operation  until  the  taxis  had  failed :  but  objected 
to  the  extraperitonaeal  herniotomy  because  of  the  danger  of  returning  un- 
seen the  contents  of  the  sac.  Eichter  is  the  only  one  to  whom  it  occurred 
pointedly  to  inquire  why  that  should  be  feared  at  the  time  of  the  operation 
which  had  not  been  feared  a  quarter  of  an  hour  earlier  when  taxis  was  being 
performed. 

Dieffenbach,  the  most  conspicuous  advocate  of  the  intraperitonaeal  method 
for  inguinal  and  femoral  hernias,  permits  the  extraperitonaeal  method  for 
umbilical  and  ventral  hernias,  because  "  it  .  anger  of  peritonitis." 

From  Celsus  we  have  reports  of  operations  for  the  cure  of  reducible  her- 
nias. At  that  time  it  was  believed  that  many  hernias  were  accompanied  by  a 

*  Kocher,  by  the  way,  has  recently  devised  an  extraperitonaeal  operation  for  the 
radical  cure  of  hernia.    (Correspondenzblatt  fur  Schweirer  Aerrte.  I 


EADICAL  CUKE  OF  IXGUIXAL  HEEXIA  269 

rent  in  the  peritonaeum.   The  incision  was  made  down  to  the  hernial  con- 
tents, and  the  supposed  rent  in  the  abdominal  wall  was  closed  by  sutur  - 

Heliodorus  gives  a  most  masterly  description  of  an  operation  for  the 
radical  cure  of  hernia  which  would  be  a  creditable  performance  today.  The 
directions  which  he  gives  for  cutting  off  the  sac  are  unique,  and  as  follows : T 

"  We  must  cut  off  the  hernial  sac  with  great  care,  for  if  we  take  awa- 
than  is  protruded,  the  result  will  be  the  production  of  a  new  hernia,  for  the 
edges  of  the  wound  will  be  slack  and  the  way  prepared  for  the  slipping  out 
again  of  the  intestines.  If  one  resects  more  than  is  protruded  by  drawing 
out  additional  peritonaeum  from  its  legitimate  resting-place,  then  "the  hernia 
will  recur,  for  the  edges  of  the  peritonaeum,  because  of  the  too  great  resec- 
tion, cannot  be  brought  together,  and  the  patient  is  in  danger  because  normal 
parts  have  been  taken  away.  In  order,  therefore,  that  we  may  not  miss 
excising  an  amount  which  is  precisely  correct  it  is  necessary  to  draw  the  sac 
outwards  by  catching  the  tip  of  the  same ;  so  soon  as  the  edges  of  the  ab- 
dominal wound  begin  to  be  everted,  enough  of  the  peritonaeum  has  been 
drawn  out  and  so  much  is  to  be  excised.  If  the  edges  of  the  abdominal  wound 
have  been  strongly  everted,  then  one  must  assume  that  more  peritonaeum  has 
been  drawn  out  than  is  necessary  and  should  pull  with  less  force.  When 
just  enough  peritonaeum  has  been  drawn  out  the  sac  is  to  be  twisted.  Having 
been  cut  off  along  a  straight  line,  the  peritonaeum  becomes  folded  upon  itself 
and  screwed  up  and  closed  so  tight  that  not  even  the  point  of  a  probe  can 
be  introduced." 

That  Heliodorus  recognized  the  existence  of  the  infundibuliform  fascia 
there  can  be  no  doubt,"  for  he  says  that  one  has  not  reached  the  true  hernial 
sac  until  the  last  of  the  layers  which  enclose  together  the  hernial  tumor  and 
the  spermatic  cord  has  been  divided.  With  the  exception  of  the  torsion  of 
the  sac,  which  we  replace  with  the  suture,  the  operation  for  the  radical  cure 
of  hernia  in  the  time  of  the  Eoman  emperors  was  quite  on  a  par  with  the 
operation  as  it  is  usually  performed  in  our  day.  Four  hundred  years  later 
the  operation  had  ceased  to  exist. 

I  am  not  inclined  to  attach  much  importance  to  the  manner  of  closing  the 
sac,  nor  to  the  level  at  which  it  is  cut  off,  nor  to  the  treatment  of  the  sac  in 
general,  provided  the  peritonaeum  is  not  allowed  to  protrude  outwards  into 
the  wound.  With  the  revival  of  the  operation  for  the  radical  cure  the  testi- 
cle was  sacrificed.  Paul  of  Aegina  directs  that  the  sac  be  ligated  at  two 
places,  and  that,  cutting  between  the  ligatures,  the  testicle  and  sac  be  re- 
moved. The  Arabians  did  not  advance  beyond  this  method.  At  length  when 
it  occurred  to  Lanfrancous  to  attempt  to  cure  hernia  without  sacrificing 
the  testicle,  he  believed  that  the  inspiration  was  from  God.  In  1882  and 
1883  ELraske  advised  castration  in  certain  difficult  cases  for  the  cure  of 
hernia. 

7Lehrbuch  der  Chirurgie.  Bd.  iii.  Eduard  Albert. 
s  Albert,  loc.  cit. 


270  RADICAL  CURE  OF  INGUINAL  HERNIA 

Guido  von  Cauliaco,  although  not  sacrificing  the  testicle  himself,  was  in- 
clined to  excuse  others  for  doing  so,  because  the  hernia  was  less  likely  to 
return  after  the  testicle  had  been  removed,  and  the  generating  power  was  not 
lost.  This  observation  of  Guido  von  Cauliaco  is  interesting  because  it  im- 
plies that  in  the  Middle  Ages  the  cord  must  have  been  regarded  as  the 
important  factor  in  the  production  of  hernia.  From  that  time  to  the  intro- 
duction of  antiseptic  surgery,  methods  of  all  sorts,  many  of  them  cruel  and 
some  barbarous,  have  been  in  vogue.  They  may  be  classified  as  follows : 

1.  Pressure  with  or  without  the  simultaneous  application  of  irritating 
and  so-called  contracting  remedies. 

2.  Caustics  and  the  actual  cautery. 

3.  Ligature  of  the  sac,  with  or  without  cutting  it  off. 

4.  Introduction  of  foreign  bodies  into  the  hernial  sac. 

5.  Healing  in  of  a  detached  portion  of  skin,  or  of  a  portion  of  impacted 
skin  into  the  abdominal  ring. 

6.  The  injection  of  irritating  fluids  within  or  outside  of  the  hernial  sac. 

7.  The  subcutaneous  suture. 

Some  of  these  methods  are  interesting  as  curiosities,  and  others  because 
they  are  still  practised. 

The  empkyvment  of  the  actual  cautery  for  the  cure  of  hernia  appealed 
particularly  to  the  knife-dreading  Arabian  school.'  After  the  rupture  had 
been  returned  and  the  cord  drawn  aside,  the  cautery  was  applied  over  the 
external  abdominal  ring  and  kept  there  until  it  had  burnt  through  the  skin 
and  hernial  sac  down  to  the  bone.  The  region  of  the  external  abdominal  ring 
having  been  described  by  Paul  of  Aegina  as  triangular,  three  different 
cautery  points  were  sometimes  used  for  this  operation — a  straight  one  for 
the  center  point,  a  gamma-shaped  one  for  the  sides,  and  a  lens-shaped  one 
for  the  surface  of  the  triangle.  The  celebrated  filium  aureum  or  punctum 
aureum,  the  golden  ligature  or  the  golden  puncture,  was  introduced  by 
Geraldus  in  Metz.  The  sac  was  laid  bare  and  then  occluded  by  a  golden 
thread  so  passed  as  not  to  include  the  spermatic  cord. 

Wood's  subcutaneous  suture  is  still  practised  in  Great  Britain,  and,  ac- 
cording to  Bassini,  has  for  years  been  the  favorite  method  in  Italy.  I  can 
remember  when  in  New  York  the  honors  were  about  equally  divided  between 
Wood's  method  and  Heaton's  injection  method.  So  late  as  1882,  J.  H. 
Warren,  of  Boston,  wrote  a  book  in  behalf  of  his  injection  method,  which  is 
essentially  the  same  as  Heaton's.  The  injection  of  alcohol  (Schwalbe)  is 
quite  popular  in  Germany  and  France. 

With  the  introduction  of  antiseptic  surgery,  or  rather  several  years  after 
Lister's  first  contributions  to  this  subject,  Annandale,  Steele,  Riesel,  Nuss- 

*  Albert,  loc.  cit. 


RADICAL  CUBE  OF  INGUINAL  HEENIA  871 

baum,  and  a  few  others,  made  bolder  attempts  to  cure  ruptures.  Although 
differing  from  each  other  in  detail,  the  methods  of  these  surgeons  were 
essentially  alike  and  are  embraced  under  the  following  heading:  Ligature 
of  the  exposed  neck  of  the  sac.  with  extirpation  or  incision  of  the  sac. 

We  are  indebted  to  antiseptic  surgery  for  reintroducing  to  us  the  operation 
of  Helicdorus. 

In  1878,  Czerny,  in  his  valuable  Beitrage  zur  Chirurgie,  records  seven 
cases  in  which  after  ligating  the  neck  of  the  sac  and  excising  the  sac  he  had 
sutured  the  pillars  of  the  external  abdominal  ring.  He  attributes  to  Bichter 
the  conception  of  the  operation,  saying  that  it  was  believed  by  Bichter  that 
for  the  radical  cure  of  hernia  not  only  must  the  hernial  sac  be  destroyed 
but  also  must  the  ring  be  narrowed.  He  courteously  concedes  also  to  Billroth, 
to  whom  his  Beitrage  are  dedicated,  credit  for  the  idea  because  Billroth  had 
said,  "  If  we  could  artificially  produce  tissues  of  the  density  and  toughness 
of  fascia  and  tendon,  the  secret  of  the  radical  cure  of  hernia  would  be  dis- 
covered." Some  years  later,  Banks  published  what  he  supposed  to  be  a  new 
operation  for  the  radical  cure  of  hernia.  Although  practically  the  same  as 
Czerny^s,  it  was  for  several  years  known  as  Banks'  operation  in  this  country 
and  in  Great  Britain. 

I  am  surprised  to  see  that  Lauenstein,  so  recently  as  1890,  accredits  Banks 
with  Czerny's  operation.  Lauenstein's  ideas  of  Czerny's  operation  were 
perhaps  obtained  from  the  latter^s  first  publication,  and  not  from  his 
Beitrage  zur  Chirurgie;  for  in  his  Beitrage  zur  Chirurgie  Czerny  regrets 
that  he  did  not  remove  the  sac  in  his  earlier  operations.  That  Banks  uses 
silver  wire  instead  of  silk  or  catgut  in  sewing  together  the  pillars  of  the 
external  abdominal  ring,  and  that  he  possibly  cuts  off  the  sac  at  a  higher 
level  than  Czerny  does,  hardly  entitles  him  to  the  operation.  The  use  in 
general  of  powerful  sewing  materials  in  surgery  is,  it  seems  to  me,  based  on 
a  misapprehension  in  pathology.  If,  for  example,  the  tension  is  so  great 
that  wire  must  be  used  to  bring  parts  together,  one  must  not  expect  perma- 
nent assistance  from  the  wire :  for  the  tissues  will  eventually  be  cut  through 
by  the  stitches  to  the  extent  necessary  to  relieve  the  tension. 

Czerny  had  not  observed  his  cases  long  enough  to  undeceive  him  as  to  the 
value  of  his  operation,  and  he  expresses  himself  very  cautiously  as  to  its 
ultimate  results.  He  sets  an  excellent  example  for  less  conscientious  sur- 
geons when,  agreeing  with  Schede,  he  does  not  propose  to  operate  upon 
controllable  ruptures  until  the  experience  of  many  years  with  ruptures 
which  cannot  be  controlled  by  a  truss  shall  have  convinced  him  of  the  safety 
and  reliability  of  his  method. 

In  1879,  Tilanus  of  Amsterdam  collected  for  the  International  Medical 
Congress  data  from  one  hundred  and  twenty-two  cases  which  had  been  oper- 


272  EADICAL  CURE  OF  INGUINAL  HERNIA 

ated  upon  by  what  were  supposed  to  be  antiseptic  methods.  Of  the  ultimate 
results  not  enough  had  been  ascertained  to  enable  one  to  form  conclusions. 
The  mortality  was  6  per  cent,  or  too  great  to  justify  operating  upon  ruptures 
which  could  be  comfortably  retained  by  a  truss. 

The  most  important  contributions  since  Czerny's  to  the  radical  cure  of 
hernia  are  from  McEwen,  McBurney,  Bassini,  Kocher,  and  Lucas- 
Championniere.  In  his  own  hands,  McEwen's  operation  seems  to  have  been 
perfect.  It  is  difficult  to  say  upon  just  what  part  of  the  operation  its  success 
depends.  I  am  not  inclined  to  ascribe  it  to  the  tampon,  although  Lauenstein 
testifies  that  he  was  fortunate  enough  to  see  the  anatomical  preparation 
from  a  patient  cured  by  McEwen's  method  who  for  years  subsequent  to  the 
operation  had  done  heavy  work  without  a  truss.  The  patient  died  of  an 
aortic  aneurism.  His  inguinal  canal  was  firmly  closed,  and  on  the  abdominal 
side  of  the  same  and  firmly  adherent  was  the  sac  folded  up  into  a  dense 
cushion,  which  strengthened  the  abdominal  wall  in  this  situation.  Unlikely 
as  this  may  seem,  we  must  unhesitatingly  accept  the  testimony  of  such  men 
as  Lauenstein  and  McEwen.  Bassini,  on  the  other  hand,  had  an  opportunity 
to  observe  at  an  autopsy  ninety-five  days  after  the  operation,  that  the  tampon 
which  he  had  made  somewhat  after  the  manner  of  McEwen's  had  been 
completely  absorbed;  not  a  trace  of  it  remained.  One  is  so  familiar  with 
the  fate  of  redundant  tissues  that  it  is  hard  to  convince  oneself  that  the 
tampon  remains  for  years  just  as  it  was  at  the  operation,  and  that  even  if 
not  entirely  absorbed  it  is  not  at  least  greatly  reduced  in  size.  The  tampon 
being  in  place,  the  first  step  of  McEwen's  operation  is  concluded.  The 
second  step  is  to  restore  the  valve-like  form  of  the  inguinal  canal.  This  is 
done  by  one  or  more  mattress  sutures  which  unite  the  conjoined  tendon  to 
the  aponeurosis  of  the  oblique  muscle.  The  application  of  these  sutures  is 
simple,  although  from  the  description  it  would  seem  to  be  complicated. 

How  much  McEwen's  wonderfully  good  results  might  be  attributed  to 
the  wearing  of  trusses  would  depend  upon  the  percentage  of  truss  wearers. 
It  is  strange  that  so  little  success  has  attended  the  practice  of  McEwen's 
operation  in  this  country.  Is  the  fault  with  the  operator  or  with  McEwen's 
description  of  the  operation?  Whatever  the  future  of  this  operation  may 
be,  McEwen  certainly  took  an  advance  step  in  the  treatment  of  inguinal 
hernia. 

McBurney's  operation  is  undoubtedly  so  well  known  to  all  Americans 
that  a  description  of  it  would  be  superfluous.  It  would  seem  to  be  the  most 
heroic  test  which  is  possible  of  scar  tissue  and  open-wound  treatment.  But 
scar  tissue,  however  thick  and  dense,  is  not  the  tissue  best  calculated  to 
recover  from  the  effects  of  blows,  or  to  permanently  withstand  the  constant 
pressure  of  the  abdominal  contents.   McBurney  has  kindly  informed  me  by 


EADICAL  CUEE  OF  IXGUIXAL  HEEXIA  273 

letter  that  although  the  hernia  has  recurred  in  some  of  his  cases,  the  per- 
centage of  recurrence  is  so  small  that  he  still  practises  his  method.  Bull 
tabulates  several  relapses  after  McBurney's  operation.  More  than  three 
years  ago  I  described  a  new  operation  for  the  cure  of  inguinal  hernia  in 
the  male.10  Six  or  eight  months  later,  Bassini  of  Padua  published  his  opera- 
tion for  the  cure  of  inguinal  hernia  'which  he  had  performed  two  hundred 
and  fifty-one  times,  with  only  seven  returns  and  no  deaths  except  one,  and 
that  from  pneumonia  after  the  wound  had  healed.  Bassini's  operation  and 
mine  are  so  nearly  identical  that  I  might  quote  his  results  in  support  of 
my  operation. 

Instead  of  trying  to  repair  the  old  canal  and  the  internal  abdominal  ring, 
as  McEwen  had  tried  to  do,  I  make  a  new  canal  and  a  new  ring.  The  new 
ring  should  fit  the  cord  as  snugly  as  possible,  and  the  cord  should  be  as 
small  as  possible.  The  skin  incision  extends  from  a  point  about  5  cm.  above 
and  external  to  the  internal  abdominal  ring  to  the  spine  of  the  pubes.  The 
subcutaneous  tissues  are  divided  so  as  to  expose  clearly  the  aponeurosis  of 
the  external  oblique  muscle  and  the  external  abdominal  ring.  The  aponeu- 
rosis of  the  external  oblique  muscle,  the  internal  oblique  and  transversalis 
muscles  and  the  transversalis  fascia  are  cut  through  from  the  external  ab- 
dominal ring  to  a  point  about  2  cm.  above  and  external  to  the  internal 
abdominal  ring.  The  vas  deferens  and  the  blood  vessels  of  the  cord  are 
isolated.  All  but  one  or  two  of  the  veins  of  the  cord  are  excised.  The  sac  is 
carefully  isolated  and  opened  and  its  contents  replaced.  A  piece  of  gauze 
is  usually  employed  to  replace  and  retain  the  intestines.  With  the  division 
of  the  abdominal  muscles  and  the  transversalis  fascia  the  so-called  neck  of 
the  sac  vanishes.  There  is  no  longer  a  constriction  of  the  sac.  The  communi- 
cation between  the  sac  and  the  abdominal  cavity  is  sometimes  large  enough 
to  admit  one's  hand.  The  sac  having  been  completely  isolated  and  its  con- 
tents replaced,  the  peritonaeal  cavity  is  closed  by  a  few  fine  silk  mattress 
sutures,  sometimes  by  a  continuous  suture.  The  sac  is  cut  away  close  to 
the  sutures.  The  cord  in  its  reduced  form  is  raised  on  a  hook  out  of  the 
wound  to  facilitate  the  introduction  of  the  six  or  eight  deep  mattress  sutures, 
which  pass  through  the  aponeurosis  of  the  external  oblique  and  through 
the  internal  oblique  and  transversalis  muscles  and  transversalis  fascia  on 
the  one  side,  and  through  the  transversalis  fascia  and  Poupart's  ligament 
and  fibres  of  the  aponeurosis  of  the  external  oblique  muscle  on  the  other. 

The  two  outermost  of  these  deep  mattress  sutures  pass  through  muscular 
tissues  and  the  same  tissues  on  both  sides  of  the  wound.  They  are  the  most 
important  stitches,  for  the  transplanted  cord  passes  out  between  them.   If 

10  Bulletin  of  The  Johns  Hopkins  Hospital,  Vol.  I,  No.  1 ;  Johns  Hopkins  Hospital 
Reports,  Vol.  II,  surgical  fasciculus,  No.  I. 
19 


274  RADICAL  CUEE  OF  INGUINAL  HEENIA 

placed  too  close  together,  the  circulation  of  the  cord  might  be  imperiled, 
and  if  too  far  apart,  the  hernia  might  recur.  They  should,  however,  be  near 
enough  to  each  other  to  grip  the  cord.  The  precise  point  out  to  which  the 
cord  is  transplanted  depends  upon  the  condition  of  the  muscles  at  the  in- 
ternal abdominal  ring.  If  in  this  situation  they  are  thick  and  firm,  and 
present  broad  raw  surfaces,  the  cord  may  be  brought  out  here.  But  if  the 
muscles  are  attenuated  at  this  point,  and  present  thin  cut  edges,  the  cord 
is  transplanted  farther  out.  The  skin  wound  is  brought  together  by  buried 
skin  sutures  of  very  fine  silk."  The  transplanted  cord  lies  on  the  aponeurosis 
of  the  external  oblique  muscle  and  is  covered  by  skin  only.  In  both  of  the 
patients  presented  you  will  feel  the  cord  in  this  situation  distinctly.  They 
were  operated  upon  two  and  three  and  one-half  years  ago. 

Bassini  believes  that  he  restores  the  inguinal  canal  to  its  physiological 
condition,  inasmuch  as  he  makes  "  a  canal  with  two  openings,  an  abdominal 
and  a  subcutaneous ;  furthermore  with  two  walls,  a  posterior  and  an  anterior, 
through  the  middle  of  which  the  spermatic  cord  passes  obliquely."  But 
the  original  canal  is  not  by  any  means  an  affair  so  simple  as  Bassini's.  To 
reproduce  the  equivalent,  anatomically  and  physiologically,  of  the  inguinal 
canal  is  impossible.  Bassini's  operation,  although  essentially  the  same  as 
my  operation,  is  different  in  some  respects.  1.  Bassini  always  brings  the 
cord  through  the  muscles  at  the  internal  abdominal  ring.  The  point  out 
to  which  I  transplant  the  cord  is  determined,  as  I  have  said,  by  the  condition 
of  the  muscles.  2.  Bassini  does  not  excise  the  superfluous  veins.  I  believe 
that  it  is  advisable  to  reduce  the  size  of  the  cord  as  much  as  is  practicable. 
3.  In  Bassini's  operation  the  cord  lies  posterior  to  the  aponeurosis  of  the 
external  oblique  muscle;  in  mine,  between  this  aponeurosis  and  the  skin. 
To  secure  for  the  cord  the  position  which  Bassini  recommends  an  additional 
row  of  stitches  is  required.  Unless  it  should  be  demonstrated  by  a  com- 
parison of  the  results  of  the  two  methods  that  there  is  something  to  be 
gained  by  these  additional  stitches,  it  would  be  well  for  the  sake  of  the 
wound  and  the  operator  to  discard  them. 

Kocher  thinks  that  the  methods  of  Bassini  and  himself  are  to  be  preferred 
to  other  methods,  McE wen's  for  example,  because  they  (the  former)  enable 
the  patient  to  get  out  of  bed  on  the  eighth  day.  I  fail  to  see  an3i;hing  in 
the  methods  of  Kocher  and  Bassini  and  myself  which  might  enable  the 
patient  to  get  out  of  bed  earlier  than  if  he  had  been  operated  upon  by  the 
method  of  McEwen.  The  time  to  be  spent  in  bed  depends  upon  the  judg- 
ment of  the  surgeon  and  not,  open  methods  excluded,  upon  the  particular 

11  Instead  of  the  interrupted  buried  skin  suture  as  shown  in  Plate  VIII,  we  now  use 
an  uninterrupted  buried  skin  suture  without  knots,  which  is  withdrawn  after  two  or 
three  weeks. 


EADICAL  CUEE  OF  IXGUIXAL  HEEXIA  275 

method.  Our  patients  are  kept  upon  their  backs  for  21  days.  Wounds 
thoroughly  healed  throughout  per  priniam  are  not  strong  in  eight  days. 
One  can  easily  tear  open  a  typically  healed  wound  which  is  not  more  than 
six  or  seven  days  old.  Xot  long  ago  in  attempting  to  restore  a  club  foot  to 
its  proper  position  I  accidentally  and  with  very  little  force  pressed  wide 
open  a  wound  which  had  healed  in  the  typical  way  and  was  eight  days  old. 

A  wound  is  certainly  stronger  on  the  fourteenth  day  than  it  is  on  the 
seventh,  and  stronger  on  the  twenty-first  day  than  on  the  fourteenth.  Just 
how  long  wounds  of  skin  and  muscle  which  have  healed  by  first  intention 
may  continue  to  increase  in  strength  we  do  not  know.  In  our  hernia  wounds, 
the  subcutaneous  ridge  of  aponeurosis  and  muscle  which  results  when  the 
parts  have  been  brought  together  properly  by  buried  mattress  stitches  does 
not  disappear  entirely  for  five  or  six  or  more  weeks.  I  sometimes  question 
the  propriety  of  allowing,  as  I  do,  my  patients  to  walk  about  on  the  twenty- 
first  day. 

The  technique  of  operations  for  the  radical  cure  of  hernia  should  be 
unusually  perfect,  because  we  have  to  violate  occasionally  what  I  consider 
to  be  one  of  the  most  important  principles  of  antiseptic  surgery.  We  have 
to  constrict  the  tissues  somewhat  with  our  deep  sutures.  It  is  not  always 
possible  to  bring  together  the  pillars  of  the  external  abdominal  ring  without 
a  little  tension.  One  can  of  course  make  relaxation  cuts,  but  these  would  be 
quite  as  undesirable  as  a  moderate  amount  of  tension.  Our  hernia  wounds 
illustrate  admirably  the  danger  of  constricting  tissues.  We  never  resort  to 
drainage  of  any  kind  for  fresh  wounds.  And  with  the  exception  now  and 
then  of  a  hernia  wound,  none  "  of  our  fresh  wounds  suppurate.  Inasmuch 
as  we  rarely  if  ever  have  occasion  to  constrict  tissues  in  other  fresh  wounds, 
it  is  almost  certain  that  the  occasional  stitch  abscess  in  a  hernia  wound 
is  due  to  tissue  constriction  plus,  of  course,  the  infection.  To  provide  for  a 
good  circulation  in  every  particle  of  tissue  in  and  immediately  about  a 
wound  is  as  much  a  part  of  our  technique  as  are  the  ordinary  antiseptic  pre- 
cautions.  The  better  the  circulation  the  less  the  likelihood  of  suppuration." 

Since  the  opening  of  The  Johns  Hopkins  Hospital,  3^  years  ago,  82 
operations  for  the  radical  cure  of  hernia  have  been  performed,  and  without 

"  Not  more  than  one  or  two  in  a  year.  Vid.  Johns  Hopkins  Hospital  Reports.  Vol.  2. 
surgical  fasciculus,  Xo.  1. 

13 1  have  performed  three  amputations  within  a  year  and  a  half  through  tissues  which 
were  almost  surety  infected  and  with  instruments  and  hands  which  were  as  surely 
infected.  Xo  attempt  was  made  to  disinfect  the  wounds  except  that  they  were  washed 
with  a  sterilized  salt  solution,  and  in  one  instance  with  warm  water  from  the  faucet. 
Great  care  was  exercised  in  ligating  and  sewing  and  dressing  to  avoid  constricting  the 
tissues  and  to  provide  against  tension.  The  wounds  were  closed  as  usual.  They  all 
healed  absolutely  by  first  intention. 


276  EADICAL  CUKE  OF  INGUINAL  HERNIA 

a  death.  Sixty-four  of  the  cases  were  males,  18  were  females.  Of  the 
females,  four  had  femoral,  13  inguinal  and  one  umbilical  hernia.  Of  the 
males,  63  had  inguinal  and  one  femoral  hernia.  Five  of  the  males  were 
operated  upon  by  Dr.  Brockway  by  McBurney's  method.  Of  these  five  cases 
two  have  recurred ;  two  have  not  been  heard  from ;  and  one,  a  boy  2£  years 
old,  is  still  well,  20  months  after  the  operation.  The  cord  in  so  young  a 
patient  is  so  very  small  that  the  hernia  might  be  cured  for  several  years  by 
almost  any  method. 

My  operation,  with  or  without  modification,  was  employed  in  58  cases. 
Of  the  cases  which  healed  per  primam,  not  one  has  recurred.  The  wounds 
which  suppurated  were  immediately  laid  wide  open  and  allowed  to  heal  by 
granulation.  For  the  result  in  such  cases  the  open  method,  and  not  mine,  is 
responsible.  There  have  been  six  recurrences — Nos.  2,  12,  24,  27,  39,  52. 
No.  2  took  cathartics  and  got  out  of  bed  a  few  days  after  the  operation. 
He  was  discharged  for  insubordination  on  the  eighth  day,  before  his  wound 
was  firm.  In  No.  12  the  cord  was  not  transplanted.  In  No.  24  a  stitch 
abscess  formed  several  weeks  after  his  discharge.  There  is  a  slight  impulse, 
on  coughing,  at  the  site  of  the  abscess.  In  No.  27  the  wound  suppurated. 
The  stitches  were  removed  and  the  wound  was  laid  wide  open  and  allowed 
to  heal  by  granulation.  This  patient  had  a  diffuse  suppurative  inflam- 
mation of  the  neck  at  the  time  of  the  operation.  No.  39,  the  wound  was 
opened  for  haemorrhage  and  allowed  to  heal  by  granulation.  No.  52,  the 
wound  suppurated,  was  laid  open,  and  healed  by  granulation.  The  patient 
has  a  flabby  abdominal  wall.  The  scar  has  stretched  throughout  its  entire 
length,  and  there  is  an  impulse  all  along  the  scar  on  coughing. 

Statistics  of  Operations  at  The  Johns  Hopkins  Hospital  for  the 
Radical  Cure  of  Hernia  " 

1.  W.  H.  R.,  aet.  8.  Large,  right,  congenital,  inguino-scrotal,  reducible 
hernia.  Operation,  13,  6,  1889.  Healed  per  primam.  Last  observation,  1,  6, 
1891,  the  result  is  still  perfect,  2  years  after  the  operation. 

2.  G.  H.,  aet.  20.  Large,  right,  oblique,  inguino-scrotal,  reducible  hernia. 
Operation,  17,  6,  1889.  Healed  per  primam.  Discharged  for  insubordina- 
tion, 24,  6,  1889.  Patient  got  out  of  bed  several  times  and  took  cathartic 
pills  without  permission.  14,  6,  1892,  there  is  a  complete  return  of  the 
hernia. 

3.  J.  B.,  aet.  48.  Very  large,  right,  oblique,  inguino-scrotal,  reducible 
hernia.  Operation,  16,  8,  1889.  The  bladder  was  caught  in  one  of  the 
stitches,  and  the  wound,  consequently,  was  laid  open  and  allowed  to  heal 
by  granulation.  Last  observation,  10,  3,  1892,  the  hernia  has  not  returned, 
2£  years  after  the  operation. 

11  A  few  cases  have  been  added  to  this  list  since  the  reading  of  the  paper. 


RADICAL  CUEE  OF  INGUINAL  HERNIA  277 

4.  M.  E.  L.,  aet.  14.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
McBurney's  operation,  19,  8,  1889.  Last  observation,  21,  3,  1892,  the  hernia 
has  not  returned,  2-|  years  after  the  operation. 

5.  J.  D.,  aet.  8.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion 9,  10,  1889.  Healed  per  primam.  Last  observation,  5,  3,  1892,  result 
still  perfect,  2  years  and  5  months  after  the  operation. 

6.  C.  I.  B.,  aet.  38.  Small,  left,  femoral,  reducible  hernia.  Operation, 
11,  10,  1889.  Healed  per  primam.  Discharged,  4,  11,  1889. 

7.  F.  F.,  aet.  7.  Small,  right,  congenital,  inguinal,  reducible  hernia. 
Operation,  12,  10,  1889.  Healed  per  primam.  Last  observation,  25,  3,  1892, 
result  still  perfect,  2  years  5  months  after  the  operation. 

8.  J.  W.  F.,  aet.  12.  Left,  oblique,  inguinal,  reducible  hernia.  Operation, 
21,  12,  1889.  Healed  per  primam.  Last  observation,  30,  1,  1890,  result  still 
perfect.   1,  3,  1892,  patient  cannot  be  found. 

9.  S.  McN.,  aet.  46.  Large,  right,  femoral,  strangulated  hernia.  Opera- 
tion, 31,  12,  1890.   Discharged,  2,  2,  1891.  Result  unknown. 

10.  L.  L.,  aet.  27.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  14,  2,  1890.  Open  wound.  21,  3,  1892,  the  hernia  has  not 
returned. 

11.  H.  S.,  aet.  37.  Large,  right,  inguinal,  reducible  hernia.  Operation, 
21,  2,  1890.  Healed  per  primam.  Last  observation,  1,  12,  1892,  linear  scar, 
result  still  perfect,  nearly  three  years  after  the  operation. 

12.  G.  G.,  aet.  28.  Large,  left,  oblique,  inguino-scrotal,  irreducible  hernia. 
Operation,  2,  5,  1890.  Cord  not  transplanted.  Healed  per  primam.  14,  10, 
1890,  the  hernia  has  recurred. 

13.  J.  H.,  aet.  39.  Small,  left,  direct,  inguinal,  reducible  hernia.  Opera- 
tion, 20,  5,  1889.  Healed  per  primam.  Last  observation,  21,  6,  1890,  the 
hernia  has  not  recurred. 

14.  E.  H.,  aet.  35.  Small,  left,  femoral,  strangulated  hernia.  Operation, 
17,  5,  1890.   Discharged,  22,  6,  1890.  Result  unknown. 

15.  E.  P.,  aet.  45.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  29,  5,  1890.  Healed  per  primam.  Last  observation,  16,  6,  1890, 
the  hernia  has  not  recurred. 

16.  H.  B.,  aet.  8.  Small,  right,  inguinal,  reducible  hernia.  McBurney's 
operation,  17,  7,  1890.   Not  heard  from  since  discharged,  23,  8,  1890. 

17.  H.  D.,  aet.  2^.  Right,  inguino-scrotal,  congenital,  reducible  hernia. 
McBurney's  operation,  17,  7,  1890.  Last  observation,  1,  3,  1892,  the  hernia 
has  not  recurred. 

18.  A.  E.,  aet.  5.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
McBurney's  operation,  23,  7,  1890.   24,  11,  1890,  the  hernia  has  recurred. 

19.  G.  W.,  aet.  45.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
McBurney's  operation,  23,  5,  1890.  Not  heard  from  since  discharged,  8,  9, 
1890. 

20.  K.  F.,  aet.  11.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
McBurney's  operation,  4,  8,  1890.  Last  observation,  27,  3,  1892,  the  hernia 
has  not  recurred. 

21.  E.  W.,  aet.  5.  Small,  left,  oblique,  inguinal,  reducible  hernia. 
McBurney's  operation,  11,  8,  1890.  11,  11,  1890,  the  hernia  has  recurred. 
Patient  wears  truss. 


278  RADICAL  CURE  OF  INGUINAL  HERNIA 

22.  D.  H.,  aet.  9.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 23,  8,  1890.  Healed  per  primam.  Last  observation,  23,  3,  1892,  linear 
scar,  result  still  perfect. 

23.  T.  Y.,  aet.  52.  Large,  right,  oblique,  inguinal,  irreducible  hernia. 
Operation,  17,  9,  1890.  The  adhesions  were  too  firm  and  too  extensive  to 
admit  of  the  reduction  of  the  hernia. 

24.  J.  C.  H.,  aet.  27.  Large,  left,  oblique,  inguinal,  reducible  hernia. 
Operation,  24,  9,  1890.  Healed  per  primam.  Last  observation,  15,  11,  1892. 
A  few  weeks  after  the  patient  had  left  the  hospital  a  small  abscess  formed 
about  one  of  the  stitches.  Just  at  this  spot  there  is  a  distinct  impulse  on 
coughing. 

25.  GT.  S.,  aet.  49.  Large,  left,  oblique,  inguino-scrotal,  irreducible  hernia. 
Operation,  27,  9,  1890.  The  operation  was  a  difficult  one  and  consumed  two 
hours.   Stitch  abscess,  1,  3,  1892.   Patient  cannot  be  found. 

26.  C.  M.,  aet.  4.  Large,  right,  inguinal,  congenital,  reducible  hernia. 
Operation,  7,  10,  1890.  Healed  per  primam.  1,  3,  1892,  patient  cannot  be 
found. 

27.  M.  C,  aet.  20.  Large,  right,  oblique,  inguino-scrotal,  reducible  hernia. 
Operation,  26,  11,  1890.  Healed  per  primam.  The  wound  had  been  healed 
nearly  three  weeks  when  an  abscess  formed  about  the  outermost  stitch. 
This  might  be  accounted  for  by  the  fact  that  the  patient  had  at  the  time  an 
acute  purulent  inflammation  of  the  neck.  Last  observation,  5,  6,  1892,  the 
hernia  is  beginning  to  recur. 

28.  W.  McS.,  aet.  3.  Large,  right,  oblique,  inguinal,  strangulated  hernia. 
Operation,  10,  11,  1890.  Healed  per  primam.  Last  observation,  25,  3,  1892, 
firm  linear  scar,  result  still  perfect. 

29.  E.  L.  P.,  aet.  7.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  21,  11,  1890.  Healed  per  primam,  except  for  a  small  stitch 
abscess.   Last  observation,  20,  3,  1892,  linear  scar,  perfect  result. 

30.  A.  M.,  aet.  15.  Left,  oblique,  inguinal,  reducible  hernia.  Operation, 
24,  11,  1890.  Healed  per  primam.  Last  observation,  28,  3,  1892,  linear  scar, 
perfect  result. 

31.  S.  P.,  aet.  30.  Small,  right,  direct,  inguinal,  reducible  hernia.  Opera- 
tion, 29,  1,  1891.  Healed  per  primam.  Last  observation,  2,  4,  1892,  linear 
scar,  perfect  result. 

32.  F.  H.,  aet.  40.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  28,  1,  1890.  Healed  per  primam.  Last  observation,  30,  3,  1891, 
linear  scar,  perfect  result. 

33.  J.  W.,  aet.  28.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  23,  1,  1891.  Healed  per  primam.  1,  6,  1892,  cannot  be  found. 

34.  F.  S.,  aet.  27.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 6,  2,  1891.  Healed  per  primam,  except  for  minute  stitch  abscess.  Last 
observation,  2,  3,  1891,  linear  scar. 

35.  J.  L.,  aet.  14.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 20,  2,  1891.  Wound  suppurated.  Last  observation,  1,  3,  1892,  hernia 
has  not  recurred. 

36.  J.  T.,  aet.  47.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  24,  2,  1891.  Healed  per  primam.  Last  observation,  15,  11,  1892, 
linear  scar,  perfect  result. 


RADICAL  CURE  OF  INGUINAL  HERNIA  279 

37.  P.  J.,  aet.  6.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 17,  3,  1891.  Healed  per  priniam.  Last  observation,  14,  4,  1891,  result 
still  perfect. 

38.  E.  K.,  aet.  27.  Small,  left,  direct,  inguinal,  reducible  hernia.  Opera- 
tion, 13,  3,  1891,  open  wound.  Last  observation,  21,  3,  1892,  the  hernia  has 
not  recurred. 

39.  E.  J.  C,  aet.  23.  Small,  right,  oblique,  inguinal,  irreducible  hernia. 
Operation,  5,  6,  1891,  the  wound  was  opened  completely  for  haemorrhage. 
Healed  by  granulation.  2,  4,  1892,  the  hernia  has  recurred. 

40.  M.  P.,  aet.  35.  Left,  oblique,  inguinal,  reducible  hernia.  Operation, 
8,  5,  1891.  Stitch  abscess.  1,  6,  1892,  patient  cannot  be  found. 

41.  F.  S.,  aet.  14  months.  Small,  right,  inguino-scrotal,  congenital,  re- 
ducible hernia.  Operation,  19,  5,  1891.  Healed  per  primam.  1,  6,  1892, 
patient  canot  be  found. 

42.  J.  K.,  aet.  4.  Right,  oblique,  inguino-scrotal,  reducible  hernia.  Opera- 
tion, 26,  6,  1891.  Wound  suppurated.  Last  observation,  5,  4,  1892,  the 
hernia  has  not  recurred. 

43.  F.  D.,  aet.  49.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  26,  6,  1891.  Stitch  abscess.  Last  observation,  3,  4,  1892,  the 
hernia  has  not  recurred. 

44.  P.  H.,  aet.  5.  Left,  oblique,  inguinal,  irreducible  hernia.  Operation, 
11,  9,  1891.  2,  10,  1891,  stitch  abscess.  1,  3,  1892,  patient  cannot  be  found. 

45.  P.  C,  aet.  28.  Small,  right,  direct,  inguinal,  reducible  hernia.  Opera- 
tion, 16,  7,  1891.  Wound  healed  per  primam.  23,  3,  1892,  patient  cannot 
be  found. 

46.  W.  G.  W.,  aet.  2£.  Small,  right,  inguino-scrotal,  congenital,  reducible 
hernia.  Operation,  25,  7,  1891.  Wound  healed  per  primam.  Last  observa- 
tion, 1,  4,  1892,  linear  scar,  perfect  result. 

47.  G.  B.,  aet.  22.  Right,  oblique,  inguino-scrotal,  reducible  hernia. 
Operation,  4,  8,  1891.  Wound  healed  per  primam.  Last  observation,  1,  7, 
1892,  linear  scar,  perfect  result. 

48.  A.  McL,  aet.  26.  Right,  oblique,  inguino-scrotal,  strangulation  her- 
nia. Operation,  8,  9,  1891.  Wound  suppurated.  Last  observation,  1,  3, 
1892,  the  hernia  has  not  recurred. 

49.  M.  W.,  aet.  11.  Right,  inguino-scrotal,  congenital,  reducible  hernia. 
Operation,  27,  8,  1891.  Wound  healed  per  primam.  Last  observation,  1,  11, 
1891,  the  hernia  has  not  recurred. 

50.  G.  B.,  aet.  3.  Small,  right,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 30,  9,  1891.   Wound  healed  per  primam.  Ultimate  result  unknown. 

51.  J.  W.  B.,  aet.  5.  Small,  left,  oblique,  inguinal,  reducible  hernia. 
Operation,  9,  10,  1891.  Stitch  abscess.  Last  observation,  3,  3,  1892,  the 
hernia  has  not  recurred. 

52.  H.  P.,  aet.  29.  Small,  right,  oblique,  inguinal,  irreducible  hernia. 
Operation,  9,  10,  1891.  Wound  suppurated.  Healed  by  granulation.  Last 
observation,  20,  3,  1892,  the  scar  has  stretched  throughout  its  entire  length. 
Truss  advised. 

53.  E.  L.  B.,  aet.  28.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  3,  12,  1891.   Wound  healed  per  primam.   Last  observation,  7,  4, 

1892,  linear  scar,  perfect  result. 


280  EADICAL  CUEE  OF  INGUINAL  HEENTA 

54.  A.  M.,  aet.  4.  Small,  right,  oblique,  inguinal,  strangulated  hernia. 
Operation,  25,  11,  1891.  Stitch  abscess.  Last  observation,  6,  4,  1892,  the 
hernia  has  not  recurred. 

55.  H.  B.,  aet.  21.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 10,  12,  1891.  Stitch  abscess.  1,  6,  1892,  patient  cannot  be  found. 

56.  H.  E.,  aet.  20.  Small,  right,  oblique,  inguinal,  irreducible  hernia. 
Patient's  hernia  has  been  once  unsuccessfully  operated  upon  by  another 
surgeon.  Operation,  8,  1,  1892.  "Wound  healed,  per  primam.  Last  observa- 
tion, 3,  1,  1893,  linear  scar,  perfect  result. 

57.  H.  H.,  aet.  2.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  12,  2,  1892.  Wound  healed  per  primam.  1,  3,  1892,  patient  can- 
not be  found. 

58.  A.  F.,  aet.  30.  Very  large,  left,  oblique,  inguino-scrotal,  reducible 
hernia.  Operation,  23,  2,  1892.  Wound  healed  per  primam.  1,  3,  1892, 
patient  cannot  be  found. 

59.  K.  H.,  aet.  30.  Large,  left,  oblique,  inguino-scrotal,  reducible  hernia. 
Operation,  4,  3,  1892.  Wound  healed  per  primam.  A  drop  or  two  of  pus 
about  one  stitch.  1,  3,  1893,  patient  cannot  be  found. 

60.  C.  S.,  aet.  28.  Small,  right,  oblique,  inguinal,  irreducible  hernia. 
Operation,  11,  3,  1892.  The  wound  healed  per  primam.  1,  6,  1892,  patient 
cannot  be  found. 

61.  J.  S.  L.,  aet.  47.  Large,  left,  oblique,  inguino-scrotal,  reducible  her- 
nia. Operation,  22,  4,  1892.  Stitch  abscess.  1,  3,  1892,  patient  cannot  be 
found. 

62.  J.  F.,  aet.  38.  Very  large,  right,  oblique,  inguino-scrotal,  strangulated 
hernia.  Operation,  12,  5,  1892.  The  wound  healed  per  primam.  Patient 
had  parotid  abscess  on  both  sides.  Last  observation,  22,  6,  1892,  linear  scar. 

63.  C.  C,  aet.  16.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 27,  5,  1892.  The  wound  healed  per  primam.  Last  observation,  27,  6, 
1892,  linear  scar. 

64.  M.  W.,  aet.  45.  Large,  left,  oblique,  inguinal,  strangulated  hernia. 
Operation,  22,  5,  1892.  Wound  healed  per  primam.  Last  observation,  1,  9, 
1892,  linear  scar,  the  hernia  has  not  recurred. 

65.  T.  Iff.,  aet.  33.  Very  large,  direct,  inguino-scrotal,  traumatic,  strangu- 
lated hernia.  Operation,  24,  5,  1892.  A  gangrenous  appendix  vermiformis 
was  excised.  The  wound  suppurated.  The  patient  was  discharged,  2,  7, 
1892,  and  cannot  now  be  found. 

66.  T.  McC,  aet.  9.  Small,  left,  oblique,  inguinal,  congenital,  irreducible 
hernia.  Operation,  27,  5,  1892.  The  wound  healed  per  primam.  Last  ob- 
servation, 23,  6,  1892,  linear  scar. 

67.  E.  C,  aet.  23.  Eight,  oblique,  inguinal,  reducible  hernia.  Operation, 
9,  6,  1892.    The  wound  suppurated.    Discharged,  4,  7,  1892. 

68.  J.  McX.,  aet.  34.  Large,  right,  oblique,  inguino-scrotal,  irreducible 
hernia.  Operation,  10,  6,  1892.  The  wound  healed  per  primam.  Discharged 
for  insolence,  25,  6,  1892.  Last  observation,  20,  2,  1893,  linear  scar,  perfect 
result. 

69.  G.  B.,  aet.  3.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 15,  6,  1892.  The  wound  healed  per  primam  except  for  a  minute  stitch 
abscess.   Discharged,  7,  3,  1892. 


EADICAL  CUKE  OF  INGUINAL  HERNIA  281 

70.  J.  N.  W.,  aet.  21.  Small,  left,  oblique,  inguinal,  reducible  hernia. 
Operation,  16,  6,  1892.  Wound  healed  per  primam.  Last  observation,  1,  9, 
1892,  linear  scar,  perfect  result. 

71.  C.  S.,  aet.  58.  Small,  right,  oblique,  inguinal,  irreducible  hernia. 
Operation,  23,  6,  1892.  The  wound  healed  per  primam.  Discharged,  23,  7, 
1892. 

72.  M.  W.,  aet.  45.  Small,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  5,  7,  1892.  The  wound  healed  per  primam.  Last  observation, 
1,  9,  1892,  linear  scar. 

73.  H.  E.,  aet.  25.  Very  large,  right,  oblique,  inguino-scrotal,  irreducible 
hernia.  Operation,  9,  8,  1892.  The  wound  healed  per  primam  except  for 
slight  suppuration  about  one  stitch.  Discharged,  8,  9,  1892,  well. 

74.  G.  S.,  aet.  52.  Small,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 1,  9,  1892.  The  wound  healed  per  primam.  Discharged,  5,  10,  1892, 
well. 

75.  A.  B.,  aet.  25.  Left,  oblique,  inguinal,  strangulated  hernia.  Opera- 
tion, 6,  10,  1892.   The  wound  healed  per  primam.   Discharged,  1,  11,  1892. 

76.  W.  K.  H.,  aet.  43.  Small,  left,  oblique,  inguinal,  reducible  hernia. 
Operation,  29, 11, 1892.  The  wound  healed  per  primam.  Discharged,  27, 12, 
1892. 

77.  C.  C,  aet.  22.  Large,  right,  oblique,  inguino-scrotal,  reducible  hernia. 
Operation,  13,  12,  1892.  The  wound  healed  per  primam.  Discharged,  18,  1, 
1893. 

78.  A.  E.,  aet.  5.  Small,  right,  oblique,  inguinal,  reducible  hernia.  A  re- 
currence after  McBurney's  operation  in  four  months.  Operation,  5,  12, 
1890.  The  wound  healed  per  primam.  Last  observation,  6,  4,  1892,  the 
hernia  has  not  recurred. 

79.  C.  M.  S.,  aet.  50.  Large,  right,  femoral,  strangulated  hernia.  Opera- 
tion, 25,  12,  1892.  Typical  healing. 

80.  B.  D.,  aet.  22.  Large,  left,  oblique,  inguinal,  reducible  hernia.  Opera- 
tion, 13,  1,  1893.  Typical  healing. 

81.  J.  G.,  aet.  59.  Very  large,  right,  oblique,  inguinal,  reducible  hernia. 
Operation,  10,  1,  1893.   The  wound  healed  per  primam. 

82.  M.  L.,  aet.  2.  Large,  right,  oblique,  inguinal,  strangulated  hernia. 
Operation,  29,  1,  1893.   Typical  healing. 

The  time  has  come  when  one  may  operate  upon  almost  every  case  of 
hernia  not  only  without  danger  to  the  patient,  but  also  with  an  almost  cer- 
tain prospect  of  success.  Those  who,  with  Bull,  have  dropped  the  term 
"  cure  "  may  take  it  up  again.  That  the  mortality  is  practically  nothing  one 
may  convince  himself  from  the  latest  statistics. 

Svensson  and  Edman  had  from  106  cases  one  death  from  enteritis  and 
nephritis  on  the  tenth  day  when  the  wound  was  perfectly  healed.  McEwen 
operated  98  times  for  the  cure  of  inguinal  hernia,  from  1879  to  1890.  The 
only  fatal  case  was  that  of  a  boy  three  years  old  who  contracted  scarlet  fever 
after  the  operation  and  died  within  thirty-six  hours.  Bassini  has  operated 
251  times  for  nonstrangulated  hernia  by  his  method,  with  but  one  death, 


282  EADICAL  CURE  OF  IXGUINAL  HERXIA 

and  this  from  pneumonia  15  days  after  the  operation.  The  wound  in  the 
fatal  case  had  healed  per  primam.  Lucas-Championniere  from  111  cases 
lost  one  from  pneumonia.  Kocher  reports  119  operations  for  the  radical 
cure  of  hernia  with  one  death.  The  cause  of  death  was  pulmonary  embolism 
15  days  after  the  operation  and  when  the  wound  was  perfectly  healed.  We 
have  operated  82  times  for  the  radical  cure  of  hernia  without  a  death. 

If  it  is  objected  that  had  it  not  been  for  the  operation  none  of  the  deaths 
above  enumerated  would  have  occurred,  we  cannot  positively  deny  it.  But 
it  is  not  improbable,  as  Kocher  cleverly  remarks,  that  if  one  should  keep 
under  observation  hundreds  of  hernia  cases  of  all  ages  and  classes  and  pre- 
sent them  every  day  with  a  good  dinner,  he  would  occasionally  be  able  to 
announce  a  death  among  them.  As  to  the  ultimate  results  I  shall  refer  only 
to  those  of  McEwen,  Bassini  and  myself.  McEwen  failed  but  once  in  98 
cases,  and  has  had  several  cases  under  observation  for  ten  years  or  longer. 
Bassini  failed  but  seven  times  in  251  cases :  one  hundred  and  eight  cases 
had  been  cured  for  from  one  to  4£  years,  33  from  one  year  to  six  months, 
and  98  from  six  months  to  one  month.  In  only  four  cases  was  the  result 
unknown.  It  is  now  nearly  four  years  that  I  have  been  operating  for  the 
cure  of  inguinal  hernia  in  the  manner  just  described  by  me,  and  thus  far 
I  have  no  failure  to  record,  if  we  exclude  the  recurrences  which  I  have 
reported  and  which  could  not  be  ascribed  to  my  method. 

Explanation  of  the  Plates 

A,  Aponeurosis  of  the  external  oblique  muscle. 
D,  Vas  deferens. 
F,  Fascia  transversalis. 
P,  Peritonaeum. 
S,  Buried  skin-stitch,  tied. 
S',  Buried  skin-stitch,  introduced  but  not  tied. 
T,  Conjoined  tendon. 
V,  Vein. 
V,  V,  Stumps  of  excised  veins. 


PLATE  XXI 


PLATE   XXII 


REPORT  OF  TWELVE  CASES  OF  COMPLETE  RADICAL  CURE 

OF  HERNIA,  BY  HALSTED'S  METHOD,  OF  OVER  TWO 

YEARS'  STANDING.   SILVER  WIRE  SUTURES  J 

Dr.  Bloodgood  has  very  kindly  written  to  all  of  the  old  hernia  cases  in 
town  and  to  several  living  out  of  town,  requesting  them  to  come  to  show 
themselves  tonight.  It  is  now  nearly  five  years  that  we  have  done  this  opera- 
tion for  the  radical  cure  of  hernia.  You  may  remember  that  a  little  more 
than  a  year  ago  we  reported  89  cases  of  hernia,  and  that  there  were  no  re- 
currences in  the  cases  of  union  by  first  intention.  In  6  cases  there  was  more 
or  less  of  a  recurrence,  but  all  of  these  cases  had  suppurated  for  some  reason 
or  other,  and  had  healed  by  granulation.  It  remains  to  be  seen  whether  or 
not  there  are  any  returns  amongst  the  cases  here  tonight. 

This  first  man  was  operated  upon  only  two  weeks  ago  today.  In  this  case 
and  other  recent  cases  we  have  used  silver  sutures  instead  of  silk,  not 
because  we  wish  anything  stronger  than  silk,  but  because  of  the  results  of 
experiments  which  Dr.  Bolton  has  kindly  made  for  us,  and  which  we  have 
made,  to  determine  the  power  of  different  metals  to  inhibit  the  growth  of 
bacteria.  This  line  of  experimentation  is  not  entirely  original  with  us. 
Dr.  Bolton  has  found  that  zinc  and  cadmium  and  copper  are  perhaps  the 
best  metals  to  inhibit  the  growth  of  organisms.  Silver  is  perhaps  the  next 
best  metal,  and  we  are  using,  therefore,  silver  wire  altogether,  both  for  deep 
buried  sutures  and  for  the  continuous  buried  skin  sutures.  This  is  a  beau- 
tiful instance  of  healing  by  first  intention. 

Since  my  last  report  of  a  year  ago  we  have  had  a  great  many  cases  of 
hernia,  and  so  far  there  have  been,  we  believe,  no  recurrences. 

Old  Cases  of  Hernia  Exhibited  at  the  Medical  Society 

Case  1. — J.  B.,  aet.  48.  Had  a  very  large  right,  oblique  inguino-scrotal, 
reducible  hernia  of  fifteen  years'  standing.  Operation  in  August,  1889 
(four  years  and  six  months  ago).  The  bladder  was  caught  in  one  of  the 
stitches,  and  the  wound  consequently  was  laid  open  and  allowed  to  heal  by 
granulation.  The  scar  now  is  firm,  depressed,  12£  cm.  long,  and  about 
1  cm.  in  width,  there  is  no  impulse  on  coughing,  no  change  in  the  cord  or 
testicles,  the  man  suffers  no  inconvenience  from  the  wound. 

1  Presented  at  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore,  May  7, 
1894. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1894,  v,  98-99. 


284  EADICAL  CUEE  OF  HERNIA 

Case  2. — F.  F.,  aet.  7  (boy).  Small,  right,  congenital,  inguinal,  reducible 
hernia.  Operation  in  October,  1889  (four  years  and  four  months  ago). 
Wound  healed  per  primam;  there  is  a  narrow  linear  scar,  no  impulse  on 
coughing,  no  change  in  cord  or  testicles,  no  discomfort  from  wound. 

Case  3. — H.  S.,  aet.  37  (colored).  Large,  right,  inguinal,  reducible  hernia 
of  two  years'  duration.  Operation  February,  1890  (four  years  ago).  Healed 
per  primam;  there  is  a  narrow  linear  scar  9  cm.  long,  firm,  no  impulse; 
the  little  fingers  can  detect  the  opening  in  the  muscle  through  which  the 
transplanted  cord  passes,  no  inconvenience  from  wound,  no  change  in  cord 
or  testicles.   Patient  does  heavy  work. 

Case  4. — E.  P.,  aet.  7  (girl).  Small,  right,  oblique,  inguinal,  reducible 
hernia  of  two  months'  duration.  Operation  November,  1890  (three  years 
and  four  months  ago).  Healed  per  primam,  except  a  small  superficial  stitch 
abscess;  the  scar  is  white,  11  cm.  long  and  about  f  cm.  wide,  firm;  no  im- 
pulse, no  discomfort. 

Case  5. — A.  E.,  aet.  5.  Small,  right,  oblique,  inguinal,  reducible  hernia 
of  four  years'  duration.  Operation  by  Dr.  Brockway  (McBurney's  method) 
in  July,  1890.  The  hernia  recurred,  and  in  November,  1890  (three  and  one- 
half  months  afterward),  a  second  operation  by  Halsted's  method  was  per- 
formed. The  wound  healed  per  primam,  notwithstanding  the  fact  that  the 
child  had  whooping-cough.  It  is  now  three  years  and  three  months  since 
the  last  operation,  and  there  is  no  return  of  the  hernia. 

Case  6. — F.  S.,  aet.  27.  Small,  left  oblique,  inguinal,  reducible  hernia  of 
two  months'  duration,  following  typhoid  fever.  Operation  February,  1891. 
Healing  per  primam,  except  for  a  small  superficial  stitch  abscess.  It  is  now 
three  years  since  the  operation.  The  scar  is  firm,  white,  12  cm.  long.  There 
is  no  impulse  on  coughing.   No  discomfort.  Testicles  and  cord  normal. 

Case  7. — J.  T.,  aet.  47.  Small,  right,  oblique,  inguinal,  reducible  hernia 
of  six  weeks'  duration.  Operation  February,  1891  (three  years  ago).  Healed 
per  primam.  The  scar  is  narrow  and  white,  13  cm.  long,  firm.  No  impulse 
on  coughing.   No  discomfort.   Testicles  and  cord  normal. 

Case  8. — W.  C.  W.,  aet.  2£.  Small,  right,  inguino-scrotal,  congenital,  re- 
ducible hernia.  Operation  July,  1891  (two  years  and  eight  months  ago). 
Scar  white,  linear,  8  cm.  long,  firm.  No  impulse  on  coughing.  No  change  in 
cord  or  testicle. 

Case  9. — G-.  B.,  aet.  22.  Eight,  oblique,  inguino-scrotal,  reducible  hernia, 
noticed  at  birth;  wore  a  truss  from  eight  to  thirteen  years  old.  Operation 
August,  1891  (two  years  and  seven  months  ago).  The  scar  is  13  mm.  wide 
and  12  cm.  long,  white,  firm.  No  discomfort.  On  coughing  there  is  a  slight 
impulse  at  the  lower  end  of  the  scar  just  above  the  pubes,  corresponding  to 
the  external  ring.  There  is  no  return  of  the  hernia. 

Case  10. — A.  McL,  aet.  26  (colored).  Eight,  oblique,  inguino-scrotal 
hernia,  reducible  for  four  years,  strangulated  on  admission.  Operation 
August,  1891  (two  years  and  seven  months  ago).  The  veins  were  very  large 


EADICAL  CURE  OF  HERNIA  285 

and  were  excised;  healing  per  primam,  except  at  the  upper  end,  in  which 
there  was  superficial  suppuration.  November,  1893,  hydrocele,  on  the  same 
side,  removed.  The  scar  is  firm;  there  is  no  impulse  on  coughing.  No 
discomfort. 

Case  11. — J.  W.  B.,  aet.  5.  Small,  left,  oblige,  inguinal,  reducible  hernia, 
following  whooping  cough  at  four  months  of  age.  Operation  September, 
1891  (two  years  and  five  months  ago).  The  wound  suppurated  at  its  upper 
third  and  healed  by  granulation.  The  scar  is  2  mm.  wide  (it  has  stretched 
some),  is  8  cm.  long,  and  firm.  No  impulse  on  coughing.  Testicle  and  cord 
normal.  There  had  been  an  epididymitis  following  the  operation,  the  in- 
duration from  which  lasted  for  six  months. 

Case  12. — H.  P.,  aet.  29.  Small,  right,  inguinal,  irreducible  hernia  of 
two  years'  duration.  Operation  October,  1891  (two  years  and  five  months 
ago).  There  were  no  adhesions  in  the  sac.  Wound  suppurated  and  healed 
by  granulation.  There  was  a  stitch  sinus  for  three  months.  The  scar  is 
firm,  but  has  stretched  a  little.  It  is  11-J  cm.  long.  The  abdominal  walls  of 
this  patient  are  so  very  thin  that  on  coughing  there  is  an  impulse  above 
Poupart's  ligament  on  both  sides.  The  impulse  is  as  great  on  one  side  as  on 
the  other. 


THE  OPERATIVE  TREATMENT  OF  HERNIA1 

The  problem  is  to  close  durably  a  rent  in  the  abdominal  wall  and  to  pro- 
vide for  the  safe  transmission  of  the  spermatic  cord.  The  cord  is  the  first 
cause  of  the  hernia  and  the  ultimate  obstacle  to  its  cure.  If  we  could  ignore 
the  cord,  the  solution  of  the  problem  would  be  comparatively  easy.  The 
larger  the  cord  the  greater  the  liability  to  a  recurrence  of  the  hernia.  The 
size  of  the  cord  depends  chiefly  upon  the  veins.  Then  why  not  reduce  the 
size  of  the  cord  by  excising  such  veins  as  may  be  superfluous  ?  By  this  pro- 
cedure the  cord  may  usually  be  reduced  to  less  than  one-third,  and  some- 
times to  one-fifth  or  one-sixth  of  its  original  size.  Two  quite  distinct  sets 
of  veins  accompany  the  vas  deferens.  When  the  tunica  vaginalis  propria 
funiculi  spermatici  has  been  divided  and  the  elements  of  the  cord  are  gently 
spread  out  by  the  fingers  the  larger  superfluous  bundle  of  veins  lies  at  some 
distance  from  the  vas  deferens.  A  few  very  delicate  veins  hug  the  vas  de- 
ferens closely.  The  veins  which  we  designate  as  "  superfluous  "  are  those 
which  I  regularly  excise  in  operations  for  varicocele.  We  have  not  thus  far 
seen  atrophy "  of  the  testicle  follow  excision  of  these  veins.  Our  cases  have 
been  observed  with  especial  reference  to  this  point.  I  think  that  there  can 
be  little  doubt  as  to  the  advisability  of  reducing  the  size  of  the  cord  by  excis- 
ing these  veins  when  they  form  a  large  bundle. 

Let  us  consider  next  the  closing  of  the  hole  in  the  abdominal  wall.  What 
tissues  shall  we  employ  and  how  shall  we  bring  these  tissues  together?  It 
has  been  demonstrated  too  often  that  the  stitching  of  the  pillars  of  the  ring 
does  not  suffice.  We  must  do  more  than  bring  free  edges  of  the  aponeurosis 
of  the  external  oblique  muscle  together.  Fortunately  we  have  muscles  so 
near  at  hand  and  so  placed  as  to  suggest  at  once  a  simple,  and  what  has 
proved  to  be  an  entirely  effective,  plastic  operation.  After  cutting  through 
the  anterior  wall  of  the  canal  down  to  the  sac,  we  continue  the  incision  in 
the  same  line,  outward  and  a  little  upward,  through  the  internal  oblique 
and  transversalis  muscles  for  an  inch  or  less.  We  divide  the  muscle-bundles 
about  at  right-angles  to  their  long  axes.  Thus  two  flaps  of  muscle  are 
obtained,  which  we  draw  down  into  the  canal  and  include  in  the  deep  stitches 

1  Am.  J.  M.  Sc,  Phila.,  1895,  n.  s.,  ex,  13-17.  (Reprinted.) 

2  May  15,  1895.  In  three  of  our  cases  atrophy  of  the  testicle  has  been  caused  by  the 
operation.  The  atrophy  is  probably  due  to  the  excision  of  the  veins,  for  it  has  occurred 
thus  far  only  in  the  cases  in  which  the  veins  were  excised. — W.  S.  HaijBTBD. 


EADICAL  CUKE  OF  HEENIA  287 

in  the  way  to  be  described.  The  uppermost  bundles  of  the  cremaster  muscle 
are  often  so  heavy  that  we  can  use  them  for  the  same  purpose.  We  close  the 
rent  which  nature  has  made  and  which  the  knife  has  enlarged  with  mattress 
sutures,  precisely  as  we  close  all  abdominal  wounds.  The  mattress  suture 
is  to  be  preferred  to  other  sutures  because  it  constricts  the  tissues  less, 
holds  greater  surfaces  in  contact,  and  insures,  ultimately,  more  accurate 
apposition  of  the  several  planes  of  tissue.  These  stitches  bring  surfaces 
together  at  the  outset,  just  as  in  sutures  of  the  intestines  the  walls  of  the 
intestine,  irrespective  of  the  stitch,  are  always  brought  together.  The  walls 
of  the  intestine  are  so  inverted  that  the  muscular  surfaces  (so-called  peri- 
tonaeal  surfaces)  are  extensively  in  contact,  the  cut  edges  never.  And  yet 
after  a  few  weeks  no  trace  of  the  inversion  remains.  Sometimes  an  almost 
imperceptible  dark  line  is  left  to  indicate  the  position  of  the  cicatrix. 
With  the  aid  of  the  microscope  we  see  that  the  finest  layer  has  met  its 
fellow  and  may  be  traced  uninterruptedly  through  the  cicatrix,  and  were 
it  not  for  the  rudimentary  character  of  a  few  of  the  villi  we  might  search 
in  vain  for  evidence  of  the  solution  in  continuity. 

Dr.  Mall,3  for  whom  I  performed  some  experiments  which  necessitated 
circular  suture  of  the  intestine,  describes  the  microscopical  appearance 
of  an  intestinal  suture  of  sixty-four  days  as  follows :  "  Fig.  12  shows  a 
section  of  this  suture  which  strikes  the  stitches.  Were  it  not  for  this  stitch 
and  a  slight  infiltration  of  that  part  with  leucocytes  the  point  of  suture 
could  not  be  made  out.  To  be  sure,  the  microscope  shows  very  rudimentary 
villi  which  could  easily  be  overlooked  when  compared  with  the  other  folds 
which  this  intestine  contains.  The  crypts  are  fully  regenerated  and  cannot 
be  differentiated  from  the  surrounding  crypts.  The  stratum  fibrosum, 
muscularis  mucosae,  submucosa,  and  two  muscular  coats  are  all  reproduced 
and  form  one  straight  line.  The  regeneration  is  so  complete  that  the  two 
layers  of  the  regenerated  muscularis  mucosae  can  be  made  out/' 

There  are  usually  six  of  these  deep  stitches.  They  are  taken  very  close 
together,  not  more  than  1  cm.  apart.  The  two  arms  of  each  stitch  are  7  or 
8  mm.  apart.  The  vas  deferens,  with  its  arteries  and  remaining  veins,  is 
brought  forward  between  the  two  outermost  stitches.  These  two  stitches  are 
closer  together  than  the  others  and  embrace  the  cord  snugly.  The  outer 
arm  of  the  outermost  stitch  is  sometimes  passed  through  uncut  muscle. 

When  the  deep  wound  is  closed  muscle  should  be  seen  throughout  the 
greater  part  of  it,  projecting  between  the  cut  edges  of  the  aponeurosis  of 
the  external  oblique  muscle.  These  edges  are  then  made  to  embrace  the  cord 
more  snugly  at  the  point  where  it  passes  between  them  by  two  very  fine 

3  Johns  Hopkins  Hospital  Reports,  vol.  i,  p.  90. 


288  EADICAL  CUKE  OF  HEKNIA 

stitches.  The  skin  incision  is  closed  with  an  uninterrupted  suture.  As  we 
approach,  in  stitching,  the  lower  inner  angle  of  the  deep  wound  the  muscle 
becomes  thinner  and  finally  gives  out.  The  aponeurosis  of  the  external 
oblique,  with  perhaps  a  few  fibres  of  the  cremaster,  is  all  that  is  left  for  the 
innermost  stitch.  If  the  aponeurosis  at  this  point  shows,  as  it  sometimes 
does,  a  tendency  to  split  when  it  is  vigorously  pulled  upon  by  a  stitch,  we 
gather  or  pucker  it  up  by  taking  running  mattress  sutures  in  place  of  the 
ordinary  mattress  sutures.  In  running  the  stitches  I  try  to  avoid  perforating 
the  aponeurosis.  The  puckering  is,  of  course,  only  a  temporary  affair,  but 
the  running  stitches  enable  us  to  close  the  lower  angle  of  the  deep  wound 
with  less  damage  to  the  aponeurosis. 

In  short,  we  close  our  hernia-wounds  precisely  as  we  close  all  wounds  of 
the  abdomen,  except  that  in  hernia  alone  we  stitch  the  peritonaeum  sepa- 
rately. In  wounds  of  the  linea  alba  we  split  the  sheaths  of  the  recti  muscle, 
whether  we  are  operating  for  the  cure  of  hernia  or  not,  that  we  may  oppose 
broad  surfaces  of  muscle  throughout  the  whole  length  of  the  incision.4  For 
the  same  reason,  and  also  that  we  may  transplant  the  cord  in  the  male  and 
the  round  ligament  in  the  female,  we  divide  the  internal  oblique  and  trans- 
versalis  muscles  when  operating  for  the  cure  of  inguinal  hernia. 

I  shall  say  but  a  few  words  at  this  time  about  our  results,  for  Dr.  Blood- 
good  will  soon  publish  a  complete  report  of  them. 

We  have  operated  one  hundred  and  sixty-five  times  for  the  cure  of  vari- 
ous forms  of  hernia  in  both  sexes  without  a  death  from  the  operation.  One 
hundred  and  six  males  with  inguinal  hernia  have  been  operated  upon  by  my 
method.  The  wounds,  with  few  exceptions,  have  healed  absolutely  per 
primam.  Thus  far  we  have  been  unable  to  find  a  single  recurrence  in  cases 
whose  wounds  healed  per  primam.  The  case  which  furnishes  the  nearest 
approach  to  a  recurrence  was  operated  upon  about  three  years  ago  and  is 
now  under  daily  observation.  The  man  has  the  physiognomy  of  a  Hindoo, 
but  is  classed  as  a  negro.  He  is  about  thirty-five  years  old,  not  much  more 
than  half-witted,  and  was  on  admission,  and  still  is,  much  emaciated  and 
exceedingly  feeble.  Within  the  first  twenty-four  hours  he  got  out  of  bed. 
Possibly  he  repeated  this  act  of  disobedience  daily.  The  wound  healed  abso- 
lutely per  primam.  There  is  at  present,  but  only  on  coughing,  a  bulging  of 
the  very  thin,  flabby  abdominal  wall  from  the  inner  almost  to  the  outer 
end  of  the  scar.  The  local  condition  is  not  bad  enough  to  demand  a  second 
operation. 

"In  a  recent  number  of  the  Centralblatt  fiir  Chirurgie,  P.  Bruns,  of  Tubingen, 
describes  and  recommends  a  method  for  the  cure  of  ruptures  in  the  linea  alba  which, 
except  that  he  does  not  employ  the  mattress  sutures,  is  identically  ours  for  closing  all 
incisions  in  the  linea  alba. 


RADICAL  CUBE  OF  HERXIA  289 

I  dislike  to  have  my  operation  referred  to  as  a  modification  of  Bassini's 
operation.  The  operations  are  undoubtedly  original  with  both  of  us,  and 
mine  was  described  several  months  before  we  had  heard  of  Bassini's  opera- 
tion. You  may  know  that  in  my  operation  the  cord  which  is  transplanted 
out  into  the  thicker  muscle  lies  superficial  to  the  aponeurosis  of  the  external 
oblique  muscle,  and  not,  as  in  Bassini's  operation,  in  a  fold  of  and  under 
this  aponeurosis.  In  Bassini's  operation  the  circulation  of  the  aponeurosis 
must  be  impaired,  both  by  the  foldings  of  the  aponeurosis  near  Poupart's 
ligament  and  by  the  stitches  which  temporarily  maintain  them.  Further- 
more, Bassini's  method  does  not,  as  he  claims,  reestablish  the  obliquity  of 
the  canal.  Bassini  believes  that  he  restores  the  inguinal  canal  to  its  physio- 
logical condition  when  he  makes  "  a  canal  with  two  openings,  an  abdominal 
and  a  subcutaneous  opening,  and  with  two  walls,  a  posterior  and  an  an- 
terior, through  the  middle  of  which  the  cord  passes  obliquely.''  But  the 
original  canal  is  not  by  any  means  an  affair  so  simple  as  Bassini's.  To  re- 
produce the  equivalent,  anatomically  and  physiologically,  of  the  inguinal 
canal  is  for  us  impossible. 

For  about  one  year  I  have  sewed  all  of  my  hernia  wounds  with  silver 
wire  and  have  covered  them  with  silver-foil.  Without  exception  the  wounds 
have  healed  absolutely  per  primam.  Not  a  single  stitch  abscess  has  been 
observed  either  during  or  subsequent  to  the  healing  of  the  wound.  Such 
absolutely  perfect  healing  of  the  hernia  wounds  we  have  not  had  heretofore, 
and  I  am  convinced  that  the  use  of  silver  as  a  suture  material  has  contributed 
somewhat  to  this  result.  We  have  tested  the  effect  of  silver  on  the  growth 
of  the  more  common  pyogenic  organisms.  I  have  here  two  Petri-plates 
which  Dr.  Bolton  has  kindly  prepared  for  me.  They  have  both  been  inocu- 
lated with  Staphylococcus  pyogenes  aureus.  In  the  centre  of  each  plate  is  a 
piece  of  silver-foil,  such  as  we  use  on  our  wounds.  Just  outside,  and  com- 
pletely surrounding  the  foil,  is  a  perfectly  clear  zone  several  millimetres 
wide.  Except  for  the  clear  zone  and  a  slightly  intensified  zone  just  outside 
of  this,  the  agar  is  quite  uniformly  cloudy.  The  cloudiness  is  due  to  the 
growth  of  the  microorganisms  with  which  the  agar  has  been  inoculated. 
Dr.  Bolton  has  studied  the  effects  of  various  metals  on  the  growth  of  bac- 
teria, and  has  recently  read  a  most  interesting  paper  on  this  subject  before 
the  Association  of  American  Physicians.  With  cadium,  zinc,  and  copper, 
Dr.  Bolton  observed  that  the  inhibitory  action  was  greater  than  with  silver. 
Prior  to  my  knowledge  of  Dr.  Bolton's  experiments  I  tried  to  use  copper 
and  brass  foil  for  protective,  and  copper  and  brass  wire  for  sutures;  but 
these  metals  corroded  the  tissues  so  much  that  I  soon  stopped  using  them. 
We  do  not  hesitate  to  employ  buried  sutures  of  silver  wire  in  sewing  tissues 
on  the  confines  of  an  infected  region.  In  cases  of  acute  suppurative  appendi- 


290  RADICAL  CURE  OF  HERNIA 

citis,  for  example,  we  close  the  wound  in  the  abdominal  wall  with  deep,  in- 
terrupted, buried  sutures."  These  wounds  are  drained  by  a  few  strips  of 
gauze.  Two  of  the  sutures  are  taken  very  close  to  this  gauze,  and  sometimes 
must  pass  through  tissues  which  are  infected.  Not  even  in  such  cases  have 
we  ever  had  a  stitch  abscess.  Once  a  silver  stitch  and  once  a  silver  bone- 
plate,  having  been  exposed  to  view  and  to  the  air  by  necrosis  of  the  overlying 
tissues,  were  allowed  to  remain  and  to  become  imbedded  in  the  granulations 
of  the  wound,  which  healed  by  suppuration.  Neither  the  stitch  nor  the  plate 
at  any  time  caused  the  slightest  disturbance  in  the  tissues  or  inconvenience 
to  the  patient. 

We  have  already  observed  much  in  the  use  of  silver  wire  that  is  worth 
recording  and  enough  to  satisfy  us  that  it  will  play  a  new  and  more  impor- 
tant role  in  the  surgery  of  the  near  future. 

5  Vide  Bulletin  of  The  Johns  Hopkins  Hospital,  November,  1894. 


THE  OPEKATIVE  TREATMENT  OF  HERNIA1 

Inasmuch  as  our  president  requests  it,  I  shall  add  a  few  words  to 
Dr.  McBumey's  exceedingly  complimentary  remarks  on  my  operation  for 
the  cure  of  inguinal  hernia.  It  was  devised  at  a  time  when  McEwen's  and 
MeBumey's  operations  were  the  only  ones  which  seemed  to  promise  a  fair 
measure  of  success. 

My  operation  is  nothing  more  or  less  than  a  substantial  sewing  up,  in  a 
very  simple  and  natural  manner,  of  a  rent  in  the  abdominal  wall.  We  enlarge 
a  little  the  rent  already  made  in  order  to  obtain  the  muscle-flaps  which  we 
draw  down  between  the  cut  edges  of  the  aponeurosis  of  the  external  oblique 
muscle,  and  to  enable  us  to  transplant  the  cord  into  the  thick  muscle. 

I  am  glad  to  have  this  opportunity  to  tell  you  that  in  three  of  our  cases 
atrophy  of  the  testicle  has  been  caused  by  the  operation,  and  to  caution  you 
against  excising  the  veins  too  indiscriminately.  It  1  as  occurred  thus  far  only 
in  cases  in  which  the  veins  have  been  excised.  For  the  present  we  shall  not 
excise  the  veins  if  they  do  not  contribute  much  to  the  size  of  the  cord. 

It  may  be  possible  to  exercise  such  care  in  isolating  the  vas  deferens  and 
its  vessels  as  to  prevent  the  occurrence  of  even  an  occasional  atrophy  of  the 
testicle. 

I  maintain,  with  Dr.  McBurney,  that  the  sac  should  be  opened  in  most 
if  not  in  all  of  the  cases.  There  are  at  least  three  good  reasons  for  this : 

1.  There  may  be  a  constriction  of  peritonaeum  higher  than  the  internal 
ring.  This  is  not  a  rare  condition.  I  have  encountered  it  at  least  twice  this 
year. 

2.  Very  often  adhesions,  particularly  of  omentum,  are  found  at  the  neck 
of  the  sac  which  might  not  be  recognized  if  the  sac  were  not  opened. 

3.  The  sac  can  be  sewed  at  a  higher  point  and  without  danger  of  wound- 
ing the  intestine  with  the  needle. 

Three  weeks  is  not  too  long  a  time  for  the  patient  to  remain  in  bed.  I  have 
experimented  on  animals  to  try  to  determine  this  point,  and  consider  that 
four  weeks,  if  possible,  would  be  better  than  three.  A  wound  younger  than 
twelve  days  can  usually  be  torn  open  with  the  fingers  with  ease. 

1  Remarks  in  discussion  of  Dr.  Christian  A.  Fenger's  paper,  "  Causes  of  hernia  of 
the  bladder  met  with  during  operations  for  inguinal  and  femoral  hernia."  American 
Surgical  Association,  New  York,  May  28-30,  1895. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1895,  xiii,  343-344. 

291 


THE  CUKE  OF  THE  MORE  DIFFICULT  AS  WELL  AS  THE 
SIMPLER  INGUINAL  RUPTURES  a 

This  communication  will,  I  hope,  be  of  interest  to  friends  who  have  asked 
for  precise  information  as  to  the  modifications  which  our  operation  for 
hernia  has  undergone  in  the  process  of  development  during  the  past  thirteen 
years,  and  of  service  to  operators  who  seek  to  obtain  in  each  instance  a  result 
as  perfect  as  possible  and  who  recognize  that  not  infrequently  there  occur 

-  -  of  hernia  requiring  for  their  cure  extraordinary  operative  procedures. 
The  present  operation  has  been  evolved  by  degrees  and  stands  for  the  experi- 
ence of  14  years  derived  from  more  than  1000  operations  for  the  cure  of 
inguinal  hernia;  features  of  the  old  where  they  seemed  unnecessary  have 
been  dropped  and  new  ones,  as  they  seemed  to  be  indicated,  added.  To 
record  even  the  cruder  general  results  of  so  many  operations  (upon  adults 
with  few  exceptions)'  for  the  cure  of  inguinal  hernia  are  required  special 
training,  some  zeal  and  a  particular  honesty  of  purpose ;  and  for  the  recog- 
nition and  interpretation  of  the  nicer  facts,  keen  perception  and  fine  tactile 
sense  are  indispensable.  A  few  drops  or  even  a  dram  of  fluid  in  the  tunica 
vaginalis  might  readily  escape  detection,  and  to  determine  slight  swelling 
or  induration  here  and  there  in  the  epididymis  and  the  relative  size  of  the 
two  testicles  may  be  difficult.  A  novice  can  usually  discover  a  distinct  recur- 
rence and  so  can  the  patient,  but  I  have  known  an  eminent  surgeon  to  over- 
look a  weakness  in  a  scar  of  his  own  making  sufficient  to  constitute,  without 
doubt,  a  recurrence.  The  surgeon  is  fortunate  and  likely  to  be  true  to  him- 
self whose  observations  are  controlled  by  mature  assistants  with  large  experi- 
ence in  the  operative  treatment  of  hernia  and  who  are  as  eager  as  he  to 
ascertain  and  state  the  exact  truth. 

'Johns  Hopkins  Hosp.  Bull.,  Bait.,  1903,  xiv,  208-214.   (Reprinted.) 
(Note. — This  article  has  special  reference  to  the  transplantation  of  the  sheath  of 
the  rectus. — Editob.) 

1  The  value  of  an  operation  for  the  cure  of  inguinal  hernia  can  hardly  be  determined 
upon  children  for  the  surgeon  is  greatly  assisted  by  nature  as  the  child  develops,  and 
he  is  not  confronted  with  the  more  difficult  problems  arising  from  an  undeveloped  or 
an  acquired  atrophy  of  the  conjoined  tendon,  or  from  fatty  degeneration  and  atrophy 
of  the  internal  oblique  muscle.  Furthermore,  the  recurrences  have  almost  invariably 
followed  operations  for  the  cure  of  very  large  and  old  ruptures,  such  as  are  impossible 
in  children.  And  to  quote  from  Bloodgood,  "  As  we  have  had  no  recurrences  "  in  chil- 
dren "  whether  the  veins  have  been  excised  or  not,  it  does  not  seem  to  make  much 
difference  what  is  done  with  the  very  small  cord." 
292 


EADICAL  CURE  OF  HERNIA  293 

If  our  operation  for  the  radical  cure  of  inguinal  hernia  has  improved, 
it  is  due  in  no  small  measure  to  the  arduous  labors  of  Dr.  Bloodgood,  whose 
valuable  contribution  3  should  be  better  known.  He  established  several  facts 
of  prime  importance  from  his  study  of  our  first  300  cases  of  inguinal  hernia. 
The  majority  of  inguinal  ruptures  are  now  easily  and  quite  well  cured  by 
a  variety  of  procedures  and  by  the  average  operator,  hence  it  is  difficult  for 
the  student  and  young  practitioner  to  comprehend  that  it  is  hardly  more 
than  a  decade  since  this  variety  of  hernia  completely  baffled  the  efforts  of 
the  best  surgeons  to  cure  it.  That  so  simple  an  operation  as  Kocher's  can 
cure  perhaps  many  of  the  milder  ruptures,  provided  the  neck  of  the  sac  is 
not  too  wide,  leads  to  the  inquiry  whether  the  features,  of  these  operations, 
upon  which  most  stress  has  been  laid  may  not  be  relatively  unimportant, 
since  operations  of  the  magnitude  of  Bassini's  and  the  author's  are  not  in 
all  cases  indispensable.  If  the  transplantation  of  the  neck  of  the  sac  can 
cure  so  many  cases,  is  it  not  possible  that  the  transplantation  of  the  cord, 
which  at  first  was  deemed  so  essential  by  Bassini  and  the  author,  may  have 
owed  its  success  in  part  to  the  fact  that  it  made  possible  this  very  high 
closure  of  the  sac's  neck?  Although  for  several  years  our  operation,  so  far 
as  transplantation  of  the  cord  and  high  closure  of  the  sac  is  concerned,  was 
even  more  radical  than  Bassini's  (the  cord  was  transplanted  into  the  sub- 
stance of  the  divided  internal  oblique  muscle),  we  were  tempted,  at  the  very 
outset,  to  test  the  relative  value  of  cord  transplantation  in  some  of  the  cases, 
and  permitted  the  entire  cord  to  lie  undislocated  and  altogether  undisturbed 
in  its  bed  and  to  trust  to  the  suture  of  the  internal  oblique  muscle  to 
Poupart's  ligament,  to  the  "  lining  of  the  wound  with  muscle  "  to  effect  a 
cure.  It  was  well  worthy  of  note,  as  Bloodgood  emphasizes  in  his  article, 
that  all  of  the  cases  treated  in  this  manner  (cord  undisturbed)  remained 
cured.  Another  fact  which  Bloodgood's  painstaking  study  established  was 
that  of  one  hundred  and  nine  cases  in  which  the  larger  bundle  of  veins  of 
the  cord  was  excised  and  the  healing  was  per  primam,  not  one  showed  a 
recurrence  or  any  weakness  at  the  site  of  the  transplanted  vas  deferens, 
whereas  in  6.4  per  cent  of  the  cases  which  healed  by  first  intention  and 
in  which  the  veins  had  not  been  excised,  there  was  a  recurrence  at  the  upper 
angle  of  the  wound,  at  the  site  of  the  transplanted  cord.  And  even  in  the 
wounds  which  suppurated,  there  was  not  a  recurrence  in  the  nine  cases  of 
vein  excision,  whereas,  of  eleven  suppurating  cases  in  which  the  cord-veins 
were  not  excised,  four  (36.3  per  cent)  recurred.  In  118  cases,  therefore,  in 
which  the  larger  bundle  of  veins  was  excised  there  was  no  recurrence  at  the 

3  Johns  Hopkins  Hospital  Reports,  vol.  vii. 


294  RADICAL  CURE  OF  HERNIA 

site  of  the  transplanted  cord  -whether  suppuration 4  occurred  or  not.  And, 
certainly,  the  cases  in  which  the  veins  were  excised,  were  not  the  simpler 
ones. 

One  of  the  most  important  of  the  facts  ascertained  by  Bloodgood  was 
the  great  variation  in  the  width  of  the  conjoined  tendon  and  the  responsi- 
bility of  the  insufficient  tendon  for  the  recurrences  at  the  lower  angle  of  the 
wound,  through  the  external  ring,  direct.  The  transplantation  of  the  rectus 
muscle  recommended  by  Bloodgood 5  to  close  this  defect  seems  to  accomplish 
what  its  originator  hoped  it  might,  although,  a  priori,  one  would  fear  that 
this  powerful  straight  muscle  must  eventually  draw  away  from  Poupart's 
ligament  to  which  it  had  been  sewed.  Is  it  not  conceivable,  however,  that 
a  new  encompassing  fascia  may  develop  about  a  transplanted  muscle  and 
that  this  fascia  may  remain  even  after  the  muscle  has  been  pulled  away? 
Experiments  upon  animals  to  determine  this  point  would  be  interesting. 
M.  Holl,  now  Professor  of  Anatomy  in  Gratz,  directed  attention  many  years 

4  Nine  suppurations  in  118  cases,  and  for  most  of  which  the  author  was  personally 
responsible,  seems  a  large  percentage  (7.6%)  even  for  hernia  cases  ten  years  ago,  but 
it  was  considered  a  good  showing  in  those  days.  Since  every  one,  including  the  oper- 
ator, has  invariably  worn  rubber  gloves,  suppuration,  even  in  the  operations  for 
hernia,  has  occurred  in  probably  less  than  1%  of  the  cases.  In  1890,  all  the  assistants 
at  an  operation,  the  nurses  and  physicians,  systematically  wore  gloves,  but  the 
operator  wore  them  only  for  special  operations,  such  as  exploratory  laparotomies, 
explorations  for  foreign  bodies,  loose  cartilages,  etc.,  in  the  joints,  suture  of  the 
fractured  patella,  etc. — in  other  words,  when  there  was  a  possibility  of  doing  serious 
harm  and  no  certainty  of  doing  great  good.  By  degrees  the  operator  wore  gloves  more 
frequently,  until  Dr.  Bloodgood  as  resident  surgeon,  and  who  had  become  thoroughly 
accustomed  to  them  as  assistant,  wore  them  invariably  as  operator  and  demonstrated 
from  our  statistics  the  necessity  of  doing  so.  It  seems  to  be  a  fact  that  one  who  has 
been  trained  to  operate  always  in  rubber  gloves  finds  it  awkward  to  operate  without 
them.  I  have  more  than  once  heard  my  assistants,  while  performing  some  insignificant 
operation  without  them,  call  for  gloves  because,  as  they  said  they  were  conscious  of 
unnatural  finger  movements,  of  a  certain  clumsiness  without  them.  With  gloves  one 
probably  acquires  special  methods  of  tying  knots,  holding  instruments,  etc.  In  our 
clinic  the  heavier  gloves  are  exclusively  used,  although  probably  every  member  of  the 
staff  has  by  predisposition  been  in  favor  of  the  thinner  gloves  and  had  to  convince 
himself  by  trial  of  the  thinner  varieties  that  the  thick  ones,  even  with  seams  on  the 
fingers,  were  preferable.  The  thin  gloves  were  too  slippery;  also  too  unsafe,  chiefly 
because  of  the  danger  of  minute  undetected  holes.  Cotton  gloves,  if  changed  very 
frequently,  are  undoubtedly  better  than  no  gloves  at  all.  If  the  operator  desires  the 
physical  property  of  the  cotton  which  enables  him  to  hold  more  securely  and  handle 
with  more  precision  the  intestines  and  viscera  he  might  wear  a  very  delicate  gauze- 
mesh  glove  over  the  rubber  or  over  two  or  three  fingers  of  the  rubber  glove.  Possibly 
a  rubber  glove  might  be  manufactured  with  a  wide  gauze  mesh  permanently  imbedded 
in  its  palmar  surface. 

*  Anton  Wolfler,  Beitrife  BUT  klinischen  Chirurgie  (Festschrift  f.  Billroth),  1892. 


RADICAL  CURE  OF  HEENIA  295 

ago  to  the  part  muscles  probably  play  in  the  determination  and  development 
of  the  fasciae. 

Hence,  so  long  ago  as  1896  we  recognized,  thanks  to  Bloodgood,  the  value 
of  the  excision  of  the  veins  of  the  cord  and  the  necessity  for  paying  more 
attention  to  the  neglected  lower  angle  of  the  wound.  Naturally,  it  was 
primarily  to  the  upper  angle  that  we  had  devoted  our  thoughts,  for,  as 
emphasized  in  one  of  the  author's  articles  on  the  subject,  "  the  cord  is  the 
first  cause  of  the  hernia  and  the  ultimate  obstacle  to  its  cure."  And  this  is 
true,  notwithstanding  the  fact  that  recurrences  at  the  lower  angle  were  at 
first  not  very  rare ;  for,  our  attention  having  been  called  to  these  lower  angle 
recurrences,  methods  to  cure  them  were  soon  found. 

The  success  attending  excision  of  the  veins  (one  hundred  and  eighteen 
cases  without  recurrence  at  the  site  of  the  transplanted  vas  deferens)  seemed 
to  justify  a  continuance  of  this  practice,  provided  it  occasioned  no  undesir- 
able results;  but  excision  of  the  veins  with  transplantation  of  the  vas 
deferens  taught  us  that,  not  infrequently,  a  hydrocele,  usually  insignificant 
in  size,  was  to  be  expected,  and  that  in  about  10  per  cent  of  the  cases  atrophy 
of  the  testicle  had  occurred.  Atrophy  of  this  organ,  however,  was  observed 
only  in  cases  complicated  by  a  very  considerable  swelling  of  the  epididymis, 
and  this  observation  of  Bloodgood's,  made  so  many  years  ago,  has  been  veri- 
fied by  our  study  of  more  than  one  thousand  operations.  Great  care  was 
exercised,  therefore,  in  excising  the  veins  and,  for  a  short  time,  a  few  months 
perhaps,  this  procedure  was  not  so  invariably  practised  by  all  of  us,  being 
reserved  for  cases  which  seemed  imperatively  to  demand  it.  We  formerly 
handled  the  cord  as,  I  presume,  almost  ever}rone  still  does;  separated  it, 
more  or  less  roughly,  by  tearing,  from  the  sac  and  its  enveloping  membranes, 
and  raised  it  on  a  hook  or  strip  of  gauze  preparatory  to  transplantation  and 
while  the  stitches  were  being  applied.  We  now  treat  the  vas  deferens  with 
great  deference,  thanks  again  to  Bloodgood.  (Vide  description  of  operation 
below. ) 

It  occurred  to  Bloodgood  before  the  publication  of  his  report  on  hernia 
that  it  might  be  well  to  split  the  cord,  transplanting  only  the  veins  to  the 
outer  angle  of  the  wound  and  permitting  the  vas  deferens  to  lie  undisturbed. 
This  method  was  finally  abandoned  by  Bloodgood  and  other  members  of 
the  staff  who  had  practised  it,  because  the  subtraction  of  the  vas  deferens 
did  not  appreciably  reduce  the  size  of  the  cord ;  furthermore,  there  was  one 
or  two  recurrences  at  the  site  of  the  transplanted  veins.  This  is  a  particularly 
good  confirmation  of  the  author's  belief  that  the  veins  are  largely  responsi- 
ble for  the  development  of  oblique  inguinal  hernia.  The  vas  deferens  con- 
tributes, relatively,  very  little  to  the  size  of  most  adult  cords,  but  the  veins, 
which  at  one  moment  make  a  bundle  as  large  as  one's  finger,  may  the  next 


296  EADICAL  CURE  OF  HERNIA 

and  when  empty  be  reduced  to  the  size  of  a  small  quill.  Is  not  this  variation 
in  the  size  of  the  cord  possibly  a  factor  in  the  production  of  hernia  ?  When 
the  hernia  is  first  developing  and  the  sac  is,  at  operation,  inside  the  internal 
abdominal  ring,  it  can  readily  be  demonstrated  by  a  little  pull  on  the  veins. 
The  fat,  too,  which  is  recognized  as  sometimes  a  probable  factor  in  the  pro- 
duction of  hernia,  accompanies  for  a  short  distance  the  veins  rather  than 
the  vas  deferens.  This  fat  when  present  should  be  excised  with  the  veins. 
For  several  years,  then,  we  have  been  excising  the  veins  in  this  careful  man- 
ner, leaving  the  vas  deferens  untransplanted,  undisturbed,  and  the  internal 
oblique  muscle  undivided.  In  a  few  cases,  however,  without,  that  I  am  aware 
of,  ultimate  damage  to  the  testicle,  we  transplanted  the  vas  deferens  to  the 
outer  angle  of  the  wound.  But  we  are  quite  certain  that,  as  a  rule,  the  less 
the  vas  deferens  is  manipulated  and  the  more  carefully  the  veins  are  ex- 
cised, the  less  is  the  subsequent  congestion  of  the  epididymis.  It  is  instruc- 
tive from  day  to  day  to  study  the  stump  of  the  veins,  the  epididymis,  the 
testicles,  etc.,  after  operations  for  hernia. 

It  is  not  the  purpose  of  this  communication  to  give  the  results  in  detail 
of  these  observations. 

In  a  recent  private  case,  urethritis  Xeisseri  made  its  appearance  a  few 
hours  after  the  operation.  We  naturally  watched  the  epididymis  on  the  oper- 
ated side  with  some  concern,  fearing  that  excision  of  the  veins  might  lower 
the  resistance  of  this  organ.  On  the  twelfth  day,  without  warning,  a  very 
slight  induration  of  the  epididymis  became  evident.  I  attributed  this  to 
the  fact  that  the  patient  carried  out  his  irrigation-treatment  badly,  for  the 
proper  6  method  of  irrigation  being  instituted,  the  swelling  of  the  epididymis 
immediately  subsided  and  the  urethral  discharge  promptly  ceased. 

6  When  the  author's  method  of  treating  gonorrhoea  can  fail  in  his  own  wards,  because 
improperly  understood,  it  is  not  strange  that  so  admirable  a  surgeon  as  Dr.  Orville 
Horwitz,  apropos  of  Janet's  work  on  the  abortive  treatment  of  gonorrhoea  by 
permanganate  of  potash,  should  write :  "  In  spite  of  the  claim  of  quick  cures  and  pre- 
vention of  complications  a  length  of  time  elapsed  before  it  began  to  be  generally 
adopted  in  this  country.  The  profession  was  skeptical  as  to  the  claims  made  for  its 
brilliant  results.  This  was  probably  due  to  the  disappointment  which  had  followed  the 
employment  of  retroinjections  of  hot  water  suggested  by  H.  Holbrook  Curtis,  and  of 
the  continuous  irrigation  with  a  hot  solution  of  mercury  bichloride,  recommended  by 
Dr.  \Y.  S.  Halsted,  which  at  the  outset  seemed  to  offer  more  benefit  to  the  patient 
than  the  conservative  methods  then  in  vogue,  but  resulting  after  a  fair  trial  by  a 
large  number  of  observers  in  being  found  valueless  and  often  dangerous;  the  employ- 
ment of  these  remedies  having  been  found  to  be  attended  with  great  discomfort  to 
the  patient  and  being  frequently  accompanied  by  severe  complications,  such  as  acute 
posterior  urethritis,  seminal  vesiculitis,  prostatitis,  and  cystitis. "  This  is  not  the  proper 
time  to  tell  how  one  must  use  the  bichloride  solutions  in  order  to  obtain  the  best 
results  which  have  been  claimed  for  it,  but  to  judge  from  my  own  experience  with 
this  method  twenty  years  ago  in  private  practice,  too  much  has  hardly  been  said  in 


EADICAL  CUEE  OF  HEENIA  297 

Four  years  ago  the  author  used,  for  the  first  time,  a  part  of  the  aponeu- 
rosis covering  the  right  rectus  muscle  to  close  the  lower  part  of  the  right 
inguinal  canal.  I  felt  compelled  in  this  case  to  resort  to  some  such  measure, 
for  the  internal  oblique  was  fatty  and  attenuated  to  a  degree  not  very  often 
seen  by  us,  and  the  rectus  muscle  did  not  seem  to  promise  so  much  as  its 
fascia  did.  This  patient  was  a  college-mate  of  mine  and  for  this  reason  I 
wished,  perhaps,  more  than  ever,  to  be  very  sure  of  the  result.  One  year  ago 
I  examined  this  patient  very  carefully  and  was  gratified  to  find  as  solid  a 
closure  as  one  could  desire.  I  considered  the  result  as  perfect  as  any  that 
I  had  seen.  Dr.  Harvey  Cushing,  house  surgeon  at  the  time,  made  a  sketch 
of  this  act  of  the  operation,  which  Brodel  has  kindly  elaborated  (vide 
Plate  XXVI).  This  procedure  may  have  a  wider  application  than  I  have 
proposed  for  it.  The  anterior  sheath  of  the  rectus  muscle  might  be  employed 
in  the  way  described  whenever  the  conjoined  tendon  is  insufficient,  whether 
the  cremaster  muscle  can  be  well  used  to  remedy  the  defect  or  not.  And 
Berger 7  has  recently  suggested  using  the  rectus  sheath  in  much  the  same 
way  in  operations  for  the  cure  of  inguino -interstitial  hernia. 

In  the  upper  part  of  the  canal  we  have  strong  tissues  and  plenty  with 
which  to  close,  and  hence  it  was  perhaps  natural  to  transplant  the  cord  to 
the  upper  angle,  to  bring  it  out  through  thick  muscle.  But  it  is  not  perfectly 
certain  that  the  cord  may  not  be  a  useful  adjunct  in  the  closing  or  filling 
in  of  the  lower  angle  in  some  cases,  and  it  is  a  fact  that  with  Bassini's 
operation  the  percentage  of  recurrence  at  the  position  of  the  transplanted 
cord  in  the  case  of  adults  has  been  quite  large,  probably  over  6  per  cent. 
Whatever  the  truth  may  be,  we  have  in  the  excision  of  the  veins  a  distinct 
contraindication  to  transplanting  the  vas  deferens,  and  thus  far  we  have 
had  no  reason  to  believe  that  the  results  would  have  been  better  if  the  vas 
deferens  had  been  transplanted,  as  was  our  custom  for  several  years,  to  the 
outer  angle  of  the  canal.  We  may  eventually  discover  that  the  transplanta- 
tion of  the  cord,  which  Bassini,  and  at  one  time  the  author,  considered  not 
only  so  important,  but  perhaps  the  principal  feature  of  the  operation,  is 
harmful  rather  than  helpful.  Briefly,  we  may  find  that  not  only  the  vas 
deferens,  but  even  the  entire  cord,  would  be  more  safely  transmitted  at  the 
lower  angle  of  the  deep  wound  than  at  the  upper.  It  would  require  a  very 
large  number  of  observations  to  determine  this  point  because  the  percentage 

its  favor.  The  bad  and  indifferent  results  probably  come  from  mismanagement  or  mis- 
conception. I  should  be  glad  at  some  future  time  to  publish  the  treatment  in  detail, 
for  it  happens  that  I  have  not  heretofore  described  or,  in  print,  claimed  anything  for 
the  method  which  rightly  bears  my  name.  I  agree  with  Dr.  Horwitz  that  irrigation 
with  hot  water  is  not  only  useless  but  dangerous. 

7  P.  Berger :  La  Hernie  inguino-interstielle  et  son  traitement  par  la  Cure  radicale. 
Revue  de  Chirurgie,  Janvier,  1902. 


29S  RADICAL  CURE  OF  HERNIA 

of  recurrences  is  so  small  in  these  days :  and  it  is  unfair  to  compare  the 
results  of  various  operations  in  the  hands  of  various  operators.  Surgeons 
do  not  seem  to  be  agreed  even  as  to  what  shall  constitute  a  recurrence,  or 
wound  suppuration,  and,  if  they  were  agreed,  the  personal  element  would 
still  count  for  much. 

The  Use  of  the  C 'remaster  Muscle. — A  device  which  we  hit  upon  in  our 
efforts  to  close  more  securely  the  lower  part  of  the  canal,  but  which  we  now 
make  use  of  as  often  as  feasible,  probably  in  over  To  per  cent  of  the  cases, 
is  the  utilization  of  at  least  a  part  of  the  cremaster  muscle,  which  we  for- 
merly cut  away.  This  is  a  step  of  the  operation  to  which  one  is  irresistibly 
drawn  in  some  cases  by  the  great  strength  of  the  cremaster  and  the  firmness 
and  extent  of  its  attachments  to  Poupart's  ligament.  A  natural  insertion, 
such  as  this,  of  the  cremaster  and  its  fascia  into  Poupart's  ligament,  has  in 
each  case  a  value  which  can  be  demonstrated  on  the  operating  table  and 
can  be  counted  upon  definitely  to  contribute  something,  and  occasionally 
perhaps  a  great  deal,  to  the  strength  of  the  abdominal  wall :  whereas  the  arti- 
ficial insertion  of  the  internal  oblique  into  Poupart's  ligament,  although 
undoubtedly  of  the  utmost  importance  and  always  to  be  tried  for,  may  occa- 
sionally and  perhaps  often  fail,  from  insufficient  muscle,  too  great  tension, 
or  gradual  redressment,  to  close  securely  even  the  upper  part  of  the  canal. 
The  lower  part  of  the  canal,  ordinarily  protected  by  the  conjoined  tendon, 
can  rarely  be  entirely  safeguarded  by  the  muscle  fibres  of  the  internal  oblique 
when  its  conjoined  tendon  is  deficient.  The  cremaster,  on  the  other  hand, 
seems  in  just  these  cases  to  serve  a  particularly  good  purpose.  The  cremaster, 
unaided,  has  repeatedly  made  such  a  complete  and  strong  looking  closure 
that  we  have  felt  the  hernia  would  be  well  cured  if  the  operation  were  aban- 
doned at  this  stage. 

I  have  today,  June  10,  1903,  examined  a  patient  whose  very  wide  inguinal 
canals  (the  gap  would  have  admitted  the  hand)  were  closed  eighteen  months 
ago  solely  by  the  cremasters  stitched  over  instead  of  under  the  internal 
oblique  muscle :  the  result,  in  the  opinion  of  those  who  examined  the  case,  is 
absolutely  perfect,  on  both  sides.  My  house  surgeon.  Dr.  Follis,  and  one  or 
two  others  examined  the  man '  with  me.   Even  had  I  known  what  the  result 

'The  history  is  briefly  this.  Male,  aet.  59  years:  Surgical  No.  12.905;  was  operated 
upon  January  15.  1902.  for  two  very  large  scrotal  ruptures,  eighteen  and  twenty-four 
inches  long  (from  external  ring  to  bottom  of  scrotum).  The  conjoined  tendons  on  both 
sides  were  almost  obliterated.  The  circumcentral  rings  easily  admitted  four  fingers. 
The  cremaster  muscles,  very  well  developed,  were  used  to  close  the  entire  dehiscence 
because  the  internal  oblique  muscles  could,  only  with  great  tension,  be  drawn  down 
to  Poupart's  ligament ;  the  former  was  stitched  in  front  of  instead  of  behind  the  latter 
muscles.  We  had  never  before  and  have  never  since  had  occasion  to  use  the  cremasters 
in  this  way.  Dr.  Mitchell,  my  house  surgeon,  operated  upon  one  side,  and  the  author 
upon  the  other. 


RADICAL  CUBE  OF  HEKXIA  299 

in  this  case  was  to  be.  I  would  have  used,  if  possible,  the  internal  oblique 
muscles  in  the  old  war,  and  hence  have  stitched  the  cremaster  under  rather 
than  over  the  former.  But  the  muscles  were  attenuated  and  not  close  at 
hand.  Stitching  the  cremaster  over  the  internal  oblique  muscle  necessarily 
precludes  the  sewing  of  the  latter  to  Poupart's  ligament.  The  closure  with 
the  cremaster  seems  almost  ideal  in  some  cases:  it  is  a  method  so  inviting 
during  the  operation,  and  so  true,  when  finished,,  to  one  of  the  great  prin- 
ciples of  surgery;  there  is  no  tension.  It  is,  in  this  respect,  as  a  plastic  opera- 
tion should  be.  What  the  ultimate  verdict  will  be  it  is  too  soon  to  predict. 
The  cremaster  fibres,  particularly  the  hypertrophied  ones,  will,  in  time. 
atrophy ;  but  when  this  occurs,  the  cremasteric  fascia,  perhaps  stronger  than 
before,  would  probably  remain,  holding  together  the  atrophied  muscle  bun- 
dles. There  can,  at  least,  no  harm  result  from  this  attempt  to  strengthen 
the  wall,  for  the  internal  oblique  muscle  has  been  used  in  the  usual  manner. 
The  worst  that  could  happen  would  be  a  recurrence,  in  a  certain  class  of 
cases,  at  the  lower  angle,  one  that  might,  possibly,  have  been  avoided  if  the 
aponeurosis  over  the  rectus  muscle  had  been  employed  instead  of  the  cremas- 
ter as  described  by  the  author.  The  future  will  decide  these  nicer  points, 
and  it  would  seem  that  only  the  nicer  points  remain  now  to  interest  the 
operator. 

Another  feature  of  the  present  operation  is  to  transplant  the  neck  of  the 
sac  as  described  below.  It  is  merely  an  additional  precaution  warranted  by 
the  good  results  obtained  by  Kocher  and  others  with  his  operation. 

And,  finally,  we  overlap  the  aponeurosis  of  the  external  oblique  muscle 
to  insure  the  union  which  a  mere  approximation  of  the  edges  of  the  aponeu- 
rosis cannot  do,  and  to  close  more  snugly  the  external  ring. 

We  still  examine  with  the  same  care,  but  no  longer  with  concern,  the 
epididymis,  testicle,  stump  of  veins,  etc.,  chiefly  to  ascertain  if  there  is 
congestion  (induration)  of  the  epididymis  or  fluid  in  the  tunica  vaginalis. 
Often  there  is  an  appreciable,  though  very  slight,  induration  of  the  epi- 
didymis, particularly  if  the  veins  have  been  ligated  through  the  dense  plexus 
very  near  the  testicle:  and  often  a  few  drops  or  a  drachm  or  two,  or  even 
more  fluid  is  present  in  the  tunica  vaginalis.  This  may  become  absorbed  in 
a  few  weeks  or  months  and  might,  when  present,  usually  not  be  noticed  by 
the  patient  except  for  the  repeated  careful  examinations.  Hydroceles  con- 
taining several  ounces  have  been  recorded  in  our  histories :  in  two  or  three 
instances  operation  for  the  cure  of  the  hydrocele  has  been  performed.  What 
the  proportion  of  hydroceles  is  to  the  cases  operated  upon  for  the  cure  of 
hernia,  without  vein  excision,  I  cannot  say  for  the  reason  that  we  excise  the 
veins  almost  invariably  nowadays,  and  in  the  days  when  the  veins  were 
not  excised  we  did  not  observe  our  cases  quite  so  keenly  with  reference  to  this 


300  RADICAL  CURE  OF  HERNIA 

point.  One  of  the  larger  hydroceles  followed,  as  I  have  said,  an  operation  in 
which  the  veins  were  neither  excised  nor  transplanted  nor  in  any  way  dis- 
turbed. The  patient,  a  navy  officer,  had  an  indirect  rupture  on  each  side. 
Both  sides  were  operated  upon  at  the  same  time  and  on  both,  hydroceles 
developed  in  a  few  days,  although  neither  epididymis  became  more  than 
just  perceptibly  indurated ;  but  the  larger  hydrocele  was  on  the  side  of  the 
undisturbed  veins  and  of  the  smaller  hernia.  Not  a  single  atrophy  of  the 
testicle  has  been  recorded  since  1899,  when  Bloodgood  published  his  report, 
and  I  believe  that  at  that  time  it  was  noted  that  not  one  had  been  observed 
for  several  years. 

Possibly  some  of  my  readers  will  ask,  "  Why  take  so  much  trouble,  why 
make  the  operation  so  complicated  when  such  good  results  as  are  published 
may  be  obtained  by  simpler  methods  ?  "  The  operation  is  not  complicated 
for  the  surgeon  competent  to  operate  for  the  cure  of  hernia,  nor  are  all  its 
details  required  for  the  simpler  cases,  and  we  do  not  know  just  what  the 
results  obtained  by  simpler  methods  are.  We  cannot  ascertain  definitely  even 
our  own  results,  although  we  make  a  great  effort  and  are  admirably  equipped 
to  do  so.  This  can  be  said,  however,  that,  since  the  publication  of  the  author's 
second  paper,  June,  1892,  not  a  single  recurrence  has  been  charged  to  him. 
One  of  the  world's  most  distinguished  surgeons,  the  inventor  of  a  clever 
hernia  operation,  made,  with  reference  to  himself,  some  such  remark  to 
the  author  three  or  four  years  ago,  and  the  next  morning  two  recurrences 
presented  themselves.  This  surgeon  permits  his  patients  to  get  out  of  bed 
in  eight  days  because,  as  he  said  to  me,  "  A  man  can  better  afford  to  be  oper- 
ated upon  three  or  four  times  for  recurrence  by  my  method  than  once  by  a 
method  like  McEwen's,  which  requires  lying  in  bed  for  five  or  six  weeks." 
In  my  experience  a  man  would,  after  operation,  prefer  to  spend  several  addi- 
tional weeks  in  bed  than  run  the  risk  of  a  recurrence.  It  is  only  before,  not 
after  the  operation  that  a  patient  objects  so  vigorously  to  the  time  to  be  spent 
in  bed. 

The  Operation. — The  several  steps  of  the  operation  are  so  well  depicted 
by  the  illustrations  of  Brodel  that  a  verbal  description  is  almost  superfluous 
for  those  who  have  the  plates. 

(I)  The  aponeurosis  of  the  external  oblique  muscle  is  divided  and  the 
two  flaps  reflected  as  in  the  Bassini-Halsted  operation. 

(II)  The  cremaster  muscle  and  fascia  is  split,  not  directly  over  the  cen- 
tre of  the  cord,  but  a  little  above  it. 

(III)  The  internal  oblique  muscle  is  made  as  free  as  possible.  A  little 
artefaction  is  here  often  necessary.  If  the  muscle  cannot  be  drawn,  without 
tension,  well  down  to  Poupart's  ligament,  it  helps,  I  think,  to  make  a  re- 
laxation cut  or  two  in  the  anterior  sheath  of  the  rectus  muscle  under  the 
aponeurosis  of  the  external  oblique  muscle.    This  sheath  being  in  part  the 


RADICAL  CURE  OF  HERNIA  301 

aponeurosis  of  the  internal  oblique  muscle,  one  can  readily  comprehend  that 
incisions  into  it,  if  properly  made,  might  be  of  service.  It  is  well,  however, 
to  postpone  making  such  incisions  until  the  sewing  of  the  internal  oblique 
muscle  to  Poupart's  ligament  is  begun,  for  then  the  amount  of  tension  can 
be  nicely  gauged  and  the  number,  length  and  precise  position  of  the  relaxa- 
tion cuts  determined.  A  second  reason  for  postponing  the  relaxation  inci- 
sions into  the  anterior  sheath  of  the  rectus  muscle  is  that  we  sometimes  use 
this  portion  of  the  rectus  sheath  to  close  the  lower  part  of  the  inguinal  canal, 
as  already  stated. 

(IV)  When  the  veins  are  large,  and  this  is  usually  the  case,  they  should 
be  excised  with  very  great  care  to  avoid  even  the  slightest  extravasation  of 
blood  into  the  tissues  about  the  smaller  veins  and  about  the  vas  deferens 
which  they  accompany.  And  the  vas  deferens,  as  first  emphasized  by  Blood- 
good,  should  not  be  raised  from  its  bed  or  handled  or  even  touched,  lest 
thrombosis  of  its  veins  occur.9  (Vide  Plate  XXV,  2.)  The  veins  should  be 
ligated  as  high  up  in  the  abdomen  as  possible,  being  pulled  down  quite 
firmly  just  before  the  ligature  (in  a  needle  with  the  blunt  end  first)  is 
passed  between  them.  As  a  precaution  against  slipping,  we  apply  two  liga- 
tures of  fine  silk,  both  for  the  abdominal  stump  and  for  the  testicle  stump 
of  the  veins.  The  farther  from  the  testicle  the  veins  are  divided,  the  better, 
provided,  of  course,  that  their  stump  is  external  to  the  external  abdominal 
ring. 

(V)  Ligation  of  the  sac  by  transfixion  or  by  purse-string  suture  at  the 
highest  possible  point.  Both  ends  of  this  suture,  after  tying,  are  threaded 
on  long  curved  needles,  then  carried  far  out  under  the  internal  oblique 
muscle  from  behind  forwards,  and,  passing  through  this  muscle,  about 
5  mm.  apart,  are  tied.  The  idea  was  suggested  to  the  author  by  Kocher's 
operation,  the  principle  being  essentially  the  same.10 

(VI)  The  lower  flap  of  the  cremaster  muscle  and  its  fascia  is  drawn  up 
under  the  mobilized  internal  oblique  muscle  and  held  in  this  position  by 
very  fine  silk  stitches,  which,  having  engaged  firmly  a  few  bundles  of  the 
cremaster,  perforate  the  internal  oblique,  preferably  where  it  is  becoming 
aponeurotic,  and  are  tied  on  the  external  surface  of  the  latter;  vide 
Plate  XXIII,  1. 

(VII)  The  internal  oblique  muscle,  mobilized,  and  possibly  further  re- 
leased by  incising  the  anterior  sheath  of  the  rectus  muscle,  is  stitched  (the 

9  The  fact  is  that  the  vas  deferens  is  frequently  accidentally  handled  or  squeezed, 
but  harm  that  we  know  of  has  never  resulted  since  we  have  recognized  the  necessity 
for  exercising  great  care  in  the  separation  and  ligation  of  the  veins. 

10 1  have  read  recently  in  the  Centralblatt  fur  Chirurgie  a  reference  to  some  other 
surgeon's  account  of  this  very  procedure,  but,  unfortunately,  cannot  recall  the  sur- 
geon's name  and  have  not  the  facilities  at  this  moment  to  hunt  for  it. 


302  RADICAL  CURE  OF  HERXIA 

conjoined  tendon  also)  to  Poupart/s  ligament  in  the  Bassini-Halsted  man- 
ner. (Vide  Plate  XXIII,  2.)  Catgut  is  usually  employed  for  this  suture. 
The  drawing  was  made  from  an  unusually  muscular  subject  and  possibly 
exaggerated  the  size  and  extent  of  the  internal  oblique  muscle,  as  well  as 
of  the  cremaster,  although  the  artist  endeavored  to  record  accurately  what 
he  saw. 

(VIII)  The  aponeurosis  of  the  external  oblique  muscle  is  overlapped, 
as  shown  in  Plate  XXIV,  1  and  2.  This  is  known  as  Andrew's  u  method, 
although  devised  independently  by  us. 

( IX )  The  skin  is  closed  with  a  buried  continuous  silver  suture,  and  the 
incision  covered  with  five  or  six  layers  of  silver  foil.  It  is  unnecessary  to 
dress  or  examine  a  wound  closed  in  this  manner  for  two  weeks,  when  the 
wire  may  be  withdrawn.  Patients  are  kept  in  bed  from  eighteen  to  twenty- 
one  days. 

TTe  hope  to  be  able  to  publish  very  soon  the  results  of  the  first  1000  opera- 
tions performed  for  the  cure  of  inguinal  hernia  at  The  Johns  Hopkins 
Hospital.  Certainly  more  than  two-thirds  of  the  operations  have  been  per- 
formed by  my  associates,  Drs.  Finney,  Bloodgood,  Cushing,  Mitchell  and 
Follis,  for  we  are  all  much  interested  in  the  subject.  Each  operator  has  been 
at  perfect  liberty  and  is  encouraged  to  perform  the  operation  according  to 
his  best  judgment.  This  fortunately  furnished  a  little  variety,  but  of  late 
the  operation  has,  in  almost  every  detail,  been  performed  just  as  the  writer 
has  described  it. 

Inasmuch  as  only  a  limited  number  of  surgeons  see  The  Johns  Hopkins 
Hospital  Reports,  in  which  Dr.  Bloodgood  published  his  article,  it  may  be 
well  to  publish  one  or  two  of  the  Summaries  which  he  prepared  with  such 
care  and  so  great  labor.  He  intends  quite  soon  to  investigate  the  condition 
of  all  those,  so  far  as  possible,  who  are  included  in  these  Summaries. 

"  StTMlLART  OF  THE  F/LTIilATE  RESULTS.     COMPLETE  TO  JuXE  1,  1899 

"  Recent  cases,  less  than  6  months,  and  cases  lost  track  of  were  not 
included. 

All  cases,  Group  I  to  V,  healing  p.  p 301  cases.     13  recur.  4.3* 

All  cases,  Group  I,  suppurating 31     "  9     "       890 

Total    332     "         22     "      6.6? 

Halsted's  operation,  Group  I,  healing  p.  p 21S  cases.       9  recur.  4.1* 

Halsted's  operation,  Group  I,  suppurating 20     "  6     "       30* 

Total,  Group  1 238     "         15     "      0.2* 

u  The  Chicago  Medical  Recorder,  August,  1895,  vol.  ix,  p.  67. 


PLATE  XXIII 


-         . 


PLATE   XXIV 


PLATE   XXV 


C0r^ 


- 


PLATE  XXVI 


RADICAL  CURE  OF  HERNIA  303 

"  Recurrence  in  Wounds  Healing  Per  Primam 

(1)  At  the  position  of  the  transplanted  cord,  veins  Cases.     Recurrences. 

excised    109  nil. 

(2)  At  the  position  of  the  transplanted  cord,  veins 

not  excised 109  7  (6.40) 

(3)  Upper  angle  of  the  wound,  cord  excised  or  not 

transplanted     83  1  (1.20) 

(4)  Lower  angle  of  the  wound,  conjoined  tendon  wide 

and  firm,  rectus  muscle  not  transplanted 264  nil. 

(5)  Lower  angle  of  the  wound,  conjoined  tendon  ob- 

literated, rectus  muscle  not  transplanted 8  5  (620) 

(6)  Lower  angle  of  the  wound,  conjoined  tendon  ob- 

literated, rectus  muscle  transplanted 14  nil. 

(7)  Lower  angle  of  the  wound,  conjoined  tendon  wide 

and  firm,  rectus  muscle  transplanted 16  nil. 

"  Recurrence  in  Wounds  Healing  by  Suppuration 

(1)  At  the  position  of  the  transplanted  cord,  veins 

excised    9  nil. 

(2)  At  the  position  of  the  transplanted  cord,  veins 

not  excised 11  4  (36.30) 

(3)  Upper  angle  of  the  wound,  cord  excised  or  not 

transplanted     11  1  (90) 

(4)  Lower  angle  of  the  wound,  conjoined  tendon  wide 

and  firm,  rectus  muscle  not  transplanted. ...      27  2  (7.40) 

(5)  Lower  angle  of  the  wound,  conjoined  tendon  ob- 

literated, rectus  muscle  not  transplanted 4  2  (500) 

Dr.  Bloodgood's  "Conclusions  as  to  the  operation  for  inguinal  hernia" 
published  in  1899 : 

"  Our  observations  prove  that  Halsted's  operation  with  the  excision  of  the 
veins  will  give  perfect  results,  except  in  those  few  cases  in  which  the  con- 
joined tendon  is  obliterated;  in  these  cases  our  observations  so  far  have 
demonstrated  that  the  transplantation  of  the  rectus  muscle  will  give  per- 
fect results. 

"  If  the  veins  could  be  excised  in  every  case  of  inguinal  hernia  and  the 
remainder  of  the  cord  transplanted  without  any  risk  of  epididymitis  and 
atrophy  of  the  testicle,  a  perfect  result  would  probably  be  accomplished  in 
every  case. 

"  The  operation  would  then  be :  The  ligation  and  excision  of  the  veins, 
the  transplantation  of  the  remaining  portion  of  the  cord  into  the  upper 
angle  of  the  divided  and  transplanted  internal  oblique  muscle,  and,  in  cases 
in  which  the  conjoined  tendon  is  obliterated,  the  transplantation  of  the  rec- 
tus muscle.  So  far  we  have  not  observed  a  single  recurrence  when  these 
procedures  have  been  adopted.  The  sole  objection  to  this  method  is  the 
danger  of  atrophy  of  the  testicle  after  excision  of  the  veins.  Atrophy  of  the 
testicle  has  been  observed  only  after  a  very  marked  epididymitis.  The  proba- 


304  EADICAL  CURE  OF  HEEXIA 

bilities  of  this  epididymitis  are  very  much  less  when  the  veins  are  excised 
without  disturbing  the  vas  deferens  and  its  immediate  vessels.  For  this 
reason  I  should  advise  that  when  the  veins  are  excised  the  remainder  of  the 
cord,  a  very  small  affair,  be  left  undisturbed.  I  am  very  much  inclined  to 
believe  that  the  cord,  reduced  to  such  a  diminutive  size  by  the  excision  of  the 
veins,  will  be  as  little  likely  to  be  the  cause  of  a  recurrence  in  the  lower 
angle  of  the  wound  as  in  the  upper  angle  when  it  is  transplanted. 

"  Cases  in  which  the  Veins  should  not  be  Excised 

"  When  during  the  dissection  of  the  sac  the  cord  is  torn  from  its  bed  in  the 
inguinal  canal  and  subjected  to  traumatism,  and  the  testicle  withdrawn 
from  the  scrotum,  the  veins  should  not  be  excised,  because  the  probabilities 
of  epididymitis  and  atrophy  are  too  great.  In  such  cases  I  would  advise  the 
transplantation  of  the  veins  alone,  so  that  the  larger  cord  is  divided,"  and 
the  wound  is  weakened  less  by  the  presence  of  a  very  small  cord  in  two 
places  than  by  the  presence  of  a  larger  cord  in  one  place,  which  from  our 
results  we  know  to  have  been  the  cause  of  a  recurrence  in  6.4  per  cent  of 
the  cases. 

"  Note,  June,  1899.  In  October,  1898,  I  performed  for  the  first  time  the 
splitting  of  the  cord,  transplanting  the  veins  only.  Since  this  date  the 
modification  has  been  followed  in  26  operations  for  inguinal  hernia.  In  12 
the  rectus  muscle  was  transplanted.  The  wounds  in  25  cases  healed  per 
primam.  In  19  cases  no  swelling  of  the  testicle  followed  operation.  In 
7  cases  there  was  slight  but  temporary  swelling.  Thrombosis  of  the  veins 
was  not  observed  in  any  of  the  26  cases.  It  is  seven  months  since  the  first 
two  operations.   Both  are  perfect  results.   The  others  are  recent  operations. 

"  When  the  bundle  of  veins  is  unusually  large,  and  complete  excision  is 
contraindicated  for  reasons  already  given,  I  have  suggested  that  a  portion 
should  be  ligated  and  excised  and  the  remainder  transplanted.  This  has 
been  done  in  a  recent  case  by  Doctor  Cushing. 

"  In  children  the  veins  should  not  be  excised ;  the  probability  of  atrophy 
is  greater  than  in  adults.  As  we  have  had  no  recurrences  whether  veins 
have  been  excised  or  not,  it  does  not  seem  to  make  much  difference  what  is 
done  with  the  very  small  cord. 

"  In  the  female  the  round  ligament  and  its  vessels  is  such  a  small  affair 
that  it  makes  little  difference  what  is  done  with  it. 

"  References  to  the  transplantation  of  the  rectus  muscle  by  Wolfler : 
Wolfler  published  his  method  of  transplantation  of  the  rectus  in  1892  in 
the  Beitrage  z.  Festschrift  f.  Th.  Billroth.  I  did  not  see  this  publication 
until  my  colleague,  Dr.  Clark,  returned  from  Germany,  in  June,  1898.  liy 
preliminary  report  had  then  just  been  published.  For  this  reason  no  men- 
tion was  made  of  Wolfler^s  work.  In  the  Archiv  fur  klinische  Chirurgie, 
June,  1898,  Dr.  Slajmer  publishes  150  operations  after  the  Wolfler  method. 
A  careful  reading  of  these  two  articles  has  convinced  me  that  this  method 
of  transplantation  of  the  rectus  differs  from  mine.  In  the  first  place  no 
special  reasons  are  given  for  the  transplanting  of  the  rectus  muscle,  while 

"  The  splitting  of  the  cord  has  been  discontinued  by  its  author. 


RADICAL  CURE  OF  HEEXIA  305 

in  my  publication  the  reason  given  for  the  transplantation  of  the  rectus  is 
to  strengthen  the  lower  portion  of  the  inguinal  canal  by  the  introduction 
of  muscle  which  is  weakened  by  the  obliteration  of  the  conjoined  tendon. 
The  description  of  the  "Wolfler  method  and  the  illustration  on  page  912  of 
the  second  article  show  that  the  rectus  muscle  is  not  transplanted  in  the 
best  way  to  strengthen  the  lower  portion  of  the  wound,  because  the  sheath  of 
the  rectus  is  not  divided  down  to  the  symphysis  pubis ;  but  the  division  of 
the  sheath  ends  at  least  2  to  3  cm.  above  the  pubic  bone.  For  this  reason 
the  transplanted  rectus  muscle  is  approximated  chiefly  over  the  upper  two- 
thirds  of  the  wound.  Ln  addition,  Wolfier  divides  the  sheath  of  the  rectus 
on  the  anterior  surface  above  the  linea  semilunaris.  In  my  method  the  sheath 
of  the  rectus  is  divided  posteriorly  and  the  belly  of  the  muscle  is  brought 
out  behind  the  internal  oblique.  I  believe  that  by  this  method  the  muscle 
can  better  be  transplanted  so  as  to  occupy  the  lower  two-thirds  of  the  wound. 
Slajmer  reports  6  recurrences,  about  6  per  cent.  In  three  of  these  cases  the 
wound  suppurated." 


21 


AN  ADDITIONAL  NOTE  ON  THE  OPEEATION  FOR 
INGUINAL  HERNIA1 

The  following  references  are  to  Bassini's  first  publications  of  his  method 
for  curing  inguinal  hernia : 

Edoardo  Bassini.  Nuovo  metodo  operativo  per  la  cura  radicale  delPemia 
inguinale.   106  pp.   Padua,  1889.   Month  is  not  stated. 

Eduardo  Bassini,  Prof,  der  klin.  Chirurgie  an  der  Konigl.  Universitat 
zu  Padua.  Ueber  die  Behandlung  des  Leistenbruches.  Arch,  f .  klin.  Chirur- 
gie, 1890,  Bd.  40,  p.  429. 

My  first  cases  were  reported  at  a  meeting  of  The  Johns  Hopkins  Hospital 
Medical  Society,  November  4,  1889,  and  were  published  in  The  Johns  Hop- 
kins Hospital  Bulletin  for  January,  1890.  Hence  Bassini's  brochure  antici- 
pated my  first  report  by  at  least  a  month  or  two.  "Whether  my  first  operation 
was  performed  before  the  appearance  of  Bassini's  pamphlet  in  Italian  I  can- 
not say,  for  the  precise  date  of  the  pamphlet  is  not  given.  In  any  event 
I  had  not  heard  of  Bassini's  operation  until  his  German  article  appeared — 
possibly  about  one  3-ear  after  my  first  operation;  neither  was  I  or  any 
American  or  German,  so  far  as  I  know,  aware  of  Bassini's  first  report  until 
the  appearance  of  the  second.  Bassini  unquestionably  has  the  priority.  Our 
operations  differed  in  several  respects,  but  in  the  essential  features  were  the 
same.  He  transplanted  the  cord  out  to  the  position  of  the  internal  ring; 
I  divided  the  internal  oblique  and  occasionally  the  transversalis  muscle  and 
transplanted  the  cord  to  a  point  considerably  external  to  the  site  of  the  in- 
ternal ring.  We  both  sutured  the  internal  oblique  muscle  to  Poupart's 
ligament ;  Bassini  placed  the  transplanted  cord  between  the  internal  oblique 
muscle  and  the  aponeurosis  of  the  external  oblique,  whereas  in  my  operation 
it  was  carried  superficial  to  this  aponeurosis.  Bassini  stressed  the  impor- 
tance of  restoring  the  obliquity  of  the  canal,  but  this  his  operation  did  not 
do,  nor  can  it  be  done.  At  the  very  outset  in  some  of  the  cases  I  omitted 
the  transplantation  feature  of  the  operation,  preserving  the  others  (the 
division  of  the  muscles,  the  high  ligation  of  the  sac,  the  suturing  of  the 
muscles  to  Poupart's  ligament),  trying  to  determine  the  essential  details  of 
the  operation  in  case  it  proved  successful.  It  soon  occurred  to  me  that  it 
might  be  well  to  reduce  the  size  of  the  cord  by  excising  the  greater  of  the 

1  Prepared  by  Dr.  William  S.  Halsted,  August  26,  1922. 
Not  previously  published. 
306 


RADICAL  CURE  OF  HERNIA  ,:   T 

two  bundles  of  veins  which  accompany  the  cord.  But  after  a  time  this  pro- 
cedure was  abandoned  because  hydrocele  followed  it  in  about  20  per  cent  of 
the  cases.  We  found  that  the  direct  hernias  recurred  more  often  than  the 
indirect  and  hence  Bloodgood  practised  suturing  the  outer  fibres  of  the 
rectus  muscle  to  Pouparf  s  ligament  in  order  to  fill  the  defect  caused  by  the 
obliteration  or  attenuation  of  the  conjoined  tendon.  Unknown  to  Blood- 
good  or  me  Wolfler  had  made  use  of  this  device  some  months  earlier.  I  never 
approved  of  this  procedure,  believing  that  the  rectus  in  contracting  would 
pull  away  from  the  abnormal  position,  and  hence  in  place  of  the  muscle 
f  bres  used  a  flap  formed  from  its  anterior  sheath.  Some  years  later  I  found 
that  Berger,  a  French  surgeon,  had  anticipated  me  by  a  few  months  in  using 
this  flap  of  fascia.  Later  I  improved  the  operation  by  overlapping  the 
aponeurosis  of  the  external  oblique  and  underlapping  (under  the  internal 
oblique)  the  split  cremaster  muscle  (cmL  Broedel's  beautiful  drawings). 
The  best  studies  of  the  ultimate  results  of  operations  for  hernia  are,  un- 
doubtedly, the  monograph  of  Bloodgood  (The  Johns  Hopkins  Hospital 
Reports,  1899)  and  the  paper  by  Taylor  (Archives  of  Surgery,  voL  I,  no.  8). 
Bloodgood  traces  the  development  of  the  operation  and  gives  the  results 
for  the  first  ten  years  or  so,  and  Taylor  continued  the  study  up  to  about 
1919.  Taylor's  paper  teaches  several  things,  the  most  significant  being  the 
fact  that  the  best  results  were  obtained  by  the  resident  surgeons  who  con- 
scientiously observed  all  the  details  of  my  operation  in  its  final  form.  Their 
percentage  of  recurrence  is  about  2.5.  The  worst  results  were  by  *  A  "  and 
■  B  "  (20  to  88  i  :  "A*  adhered  to  the  Bassini  operation  and  "  B," 

proclaiming  incessantly  that  any  operation  would  cure  hernia,  made  light 
of  the  details  upon  which  I  insisted.  Dr.  Gushing  made  an  important  con- 
tribution in  performing  the  operation  under  local  anaesthesia.  He  blocked 
the  nerves  as  I  had  done  in  other  operations.  The  reviewers  of  Taylor's 
paper  have  without  exception  missed  almost  all  of  the  lessons  which  it 
teach* 

It  gratified  me  to  note  that  in  twenty  years  I  have  probably  not  had  a 
recur:  the  more  remarkable  because  most  of  these  cases  were 

operated  upon  between  ten  and  twenty  years  ago.  It  would  weary  you  to 
have  me  die  subject  farther;  but  I  have  spoken  only  of  points  which 

are  essential  to  a  superficial  understanding  of  the  subject  We  have  been 
unable  to  demonstrate  that  the  transplantation  of  the  cord  is  advantageous 
and  hence,  years  ago,  discarded  this  detail  of  the  operation.  Obviously  it 
is  better  to  leave  the  cord  undisturbed  in  its  bed  unless  it  can  be  proved 
that  transplantation  of  it  gives  the  better  results.  Dr.  Karl  Schlaepfer  tells 
me  that  the  German  surgeons,  with  few  exceptions,  have  not  abandoned 
the  transplantation  of  the  cord.   Bassini  has  made  no  contribution  to  the 


308  RADICAL  CUEE  OF  HERNIA 

subject,  I  am  quite  sure,  since  1890.  There  is  not  in  any  language  a  study 
of  the  ultimate  results,  or  of  the  relative  importance  of  the  various  details 
of  the  operation  comparable  to  ours.  Indeed  I  have  not  seen  a  single  paper 
since  Bassini's  which  contributed  anything  new.  Kocher's  operation  and 
Leisrink's,  although  clearly  not  advisable,  tend  to  strengthen  my  conviction 
that  the  most  important  feature  of  the  operation  is  the  high  ligation  of  the 
sac.  Prior  to  Bassini's  publications  inguinal  hernia  had  rarely  been  cured. 
The  best  operation  up  to  that  time  was  McEwen's.  This  was  in  a  measure 
a  subcutaneous  operation  and  so  difficult  to  perform  that  it  was  rarely 
undertaken  by  others;  but  it  necessitated  a  high  closure  of  the  neck  of  the 
sac  because  in  making  a  pad  of  the  folded  sac  which  he  sutured  at  the  site 
of  the  internal  ring  he  undoubtedly  closed  off  the  neck  of  the  sac  at  a  high 
point.  He  cured  nine(?)  cases,  some  of  them  for  five  years  or  more,  as  I 
recall  the  facts.  His  operations  were  in  the  days  when  surgeons  hesitated 
to  make  long  incisions  and  free  exposures  and  careful  dissections  of  the 
region.  I  shall  be  interested  to  ascertain  McEwen's  early  attitude  towards 
antisepsis.  I  have  an  impression  that  he  was  not  an  ardent  supporter  of 
Lister  at  the  outset.  The  cure  of  inguinal  hernia  may  be  listed  with  the 
triumphs  of  surgery. 


SURGERY  OF  THE  BLOOD  VESSELS 

AND 

EXPERIMENTAL  SURGERY  OF  THE  LUNGS 


LIGATION  OF  THE  FIEST  PORTION  OF  THE  LEFT 

SUBCLAVIAN  ARTERY  AND  EXCISION  OF  A 

SUBCLAYIO-AXILLARY  ANEURISM l 

Dr.  Halsted  exhibited  the  patient  and  gave  the  following  history : 

Levin  Waters  (Plate  XXYII),  colored,  aet.  52  years,  was  admitted  to 
the  hospital  April  30,  1892.  Patient  is  a  vigorous  man,  gives  a  good  family 
history  and  denies  having  had  syphilis.  Perfectly  well  until  eight  months 
ago :  he  then  noticed  a  small  swelling  about  the  size  of  a  madeira  nut  under 
the  left  clavicle.  He  is  sure  that  there  was  at  this  time  a  distinct  pulsation 
in  the  tumor.  He  "  could  feel  it  beat  like  his  heart  "  when  he  put  his  fingers 
upon  it.  The  tumor  has  grown  rapidly  since  it  was  first  observed.  Until 
one  month  before  the  operation  the  patient  worked  regularly,  did  heavy 
lifting,  etc.,  and  had  experienced  little  or  no  discomfort  from  the  aneurism. 
His  only  symptoms  were  a  slight  numbness  of  the  left  hand  and  forearm, 
and,  subsequently,  a  shortness  of  breath  and  a  hoarseness — both  of  which 
he  attributed  to  a  cold. 

Patient  says  that  he  has  never  had  a  pain  which  could  be  referred  to  the 
tumor. 

On  admission,  the  patient  had  an  almost  spherical,  perfectly  smooth  tu- 
mor under  the  left  clavicle.  It  was  somewhat  flattened  on  the  side  which 
pressed  against  the  chest  wall,  and  measured  42  cm.  in  circumference  at  its 
base.  The  middle  third  of  the  clavicle  was  overlapped  and  almost  concealed 
by  the  tumor ;  the  lower  margin  of  the  tumor  touched  the  fourth  rib. 

Internally  it  extended  to  within  5  cm.  of  the  left  sterno-clavicular  articu- 
lation, and  externally  to  within  4  cm.  of  the  coracoid  process.  The  skin  over 
the  tumor  appeared  to  be  normal.  It  was  only  after  careful  inspection  that 
pulsation  could  be  seen.  To  the  touch  the  tumor  was  quite  solid  but  elastic, 
and  it  was  not  easy  to  feel  the  feeble  expansile  pulsation.  No  pulse  could 
be  felt  at  the  wrist  nor  anywhere  below  the  aneurism.  The  left  arm  was 
neither  swollen  nor  perceptibly  cooler  than  the  right.  The  cut  gives  one  a 
very  good  idea  of  the  size  and  situation  of  the  tumor. 

The  Operation. — The  skin  incisions:  1.  Horizontal,  about  33  cm.  long, 
from  the  sternal  notch  to  the  acromioclavicular  articulation,  and  thence 
down  the  arm  to  the  lower  border  of  the  major  pectoral  muscle  over  the 
greatest  convexity  of  the  tumor.  2.  Ascending,  vertical,  about  5  cm.  long, 
from  the  inner  end  of  the  horizontal  incision.  3.  Descending,  vertical,  about 
10  cm.  long,  from  the  middle  of  the  horizontal  incision.  4.  Ascending,  ver- 
tical, about  4  cm.  long,  from  the  horizontal  incision  at  the  acromioclavicular 
articulation. 

1  Presented  before  The  Johns  Hopkins  Hospital  Medical  Society,  Baltimore.  May 
23.  1892. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1892,  iii,  93. 

311 


312  SUBCLAVIO-AXILLAKY  ANEURISM 

The  flaps  so  outlined  were  reflected:  the  first,  upwards  and  outwards; 
the  second,  downwards  and  inwards;  the  third,  downwards  and  outwards. 
The  inner  third  of  the  clavicle  was  then  excised.  The  middle  third  of  the 
clavicle  was  somewhat  eroded  by  the  aneurism  which  overlapped  it  a  little. 

The  wall  of  the  aneurism  was  inflamed,  soft,  and  so  very  thin  where  it 
pressed  upon  the  bone  that  it  would  have  been  imprudent  to  attempt  to  dis- 
sect this  part  of  the  clavicle  from  the  tumor. 

The  next  step  in  the  operation  was  the  deligation  of  the  left  subclavian 
artery.  This  portion  of  the  artery  had  been  drawn  down  by  the  tumor,  so 
as  to  occupy  a  horizontal  position  rather  than  a  vertical  one.  It  was  entirely 
concealed  by  the  subclavian  vein,  and  lay  below  and  behind  the  vein  instead 
of  above  and  behind  it.  I  thought  for  a  moment  that  it  might  be  necessary 
to  excise  a  portion  of  the  first  rib  to  expose  the  artery.  Two  strong  silk 
ligatures  were  applied  to  the  artery  as  it  emerged  from  the  chest,  and  the 
vessel  was  divided  between  them.  The  deltoid  muscle  was  cut  through  a 
little  below  the  clavicle,  and  the  clavicle  sawed  through  at  about  2£  cm. 
from  its  outer  end.  The  aneurism,  the  greater  part  of  the  clavicle,  a  piece 
of  the  deltoid  muscle  and  about  6  cm.  of  the  subclavio-axillary  vein  were 
then  removed  in  one  piece.  The  vein  was  intimately  adherent  to  the 
aneurism.  The  axillary  artery  was  ligated  at  the  beginning  of  its  second 
part.  The  operation  as  a  whole  was  a  tedious  one  and  consumed  3£  hours. 
The  wound  was  closed  with  interrupted  buried  skin  sutures  of  fine  black 
silk.  The  large  dead  space  incompletely  covered  by  the  skin  was  bridged 
over  with  gutta-percha  tissue. 

This  is  the  aneurismal  sac  and  this  the  laminated  clot  which  occupied  and 
almost  completely  filled  it.  The  aneurism  is,  as  you  see,  a  so-called  true 
aneurism. 

At  this  the  second  dressing,  13  days  after  the  operation,  it  may  be  ob- 
served that  the  dead  space  is  almost  completely  filled  with  a  blood  clot. 
This  clot  has  not  broken  down  and  is  almost  completely  replaced  by  granu- 
lation tissue.  The  patient  has  not  had  an  unpleasant  symptom  since  the 
operation. 

The  left  arm  has  never  swelled  and  has  at  no  time  been  cold.  For  a  few 
days  only  there  was  a  slight  numbness  of  the  tips  of  the  fingers  and  par- 
ticularly of  the  thumb.  The  case  was  altogether  a  most  fortunate  one  for 
operation  in  that,  thanks  to  the  clot  which  occupied  the  sac,  the  collateral 
circulation  had  already  been  well  established. 

This  case  is,  perhaps,  the  only  successful  one  of  deligation  of  the  first 
part  of  either  subclavian  artery,  and  the  first  one  of  complete  extirpation 
of  a  subclavio-axillary  aneurism. 

The  deligation  of  the  first  part  of  the  subclavian  artery  has  been  effected 
once  before,  in  1846,  by  Dr.  Kearney  Rodgers  of  New  York,  and  attempted 
once  by  Sir  Astley  Cooper.  Dr.  Rodgers'  case  terminated  fatally  on  the 
16th  day  from  secondary  haemorrhage.  "  At  the  autopsy  a  large  irregular 
lacerated  opening  was  found  in  the  pleura  and  the  cavity  was  filled  with 
coagulated  blood."    "  The  artery  had  been  completely  divided  by  the  liga- 


PLATE   XXVII 


Levin  Watt 


SUBCLAVIO-AXILLARY  ANEURISM  313 

ture  which  was  found  loose  in  the  wound.  The  stump  of  the  subclavian, 
between  the  aorta  and  the  ligature,  presented  the  appearance  of  a  round, 
solid  cord  about  one  and  a  quarter  inches  long,  impervious  to  water  and 
air."  Be}rond  the  ligature  no  plug  other  than  a  soft,  quite  recent  clot  occu- 
pied the  lumen  of  the  artery;  the  vertebral  was  given  off  immediately  at 
the  point  of  ligature  and  contained  a  little  clot,  evidently  formed  only  just 
before  death ;  the  internal  mammary,  also,  was  patulous  and  healthy." 

Sir  Astley  Cooper  abandoned  the  attempt  to  tie  this  vessel,  thinking  that 
he  had  wounded  the  thoracic  duct. 

The  first  part  of  the  right  subclavian  has  been  deligated  twelve  or  more 
times,  with  a  fatal  result  in  each  case.  At  least  nine  of  the  cases  died  of 
secondary  haemorrhage  from  the  distal  side  of  the  ligature. 

I  find  practically  but  one  comment  from  surgeons  on  these  results,  viz., 
if  absorbable  ligatures  had  been  used  and  if  the  coats  of  the  artery  had  not 
been  divided,  the  mortality  from  secondary  haemorrhage  might  have  been 
less.   I  would  suggest,  rather,  that  the  aneurism  be  excised. 

Note. — July  9th,  60  days  after  operation.  The  wound  has  healed  in  an  ideal  way. 
The  numbness  at  the  tip  of  the  left  thumb  has  not  completely  vanished.  No  pulse 
as  yet  is  to  be  felt  at  the  wrist.  The  patient  has  an  excellent  use  of  his  arm. 


THE  PARTIAL  OCCLUSION  OF  BLOOD  VESSELS,  ESPECIALLY 
OF  THE  ABDOMINAL  AORTA  * 

A  PRELIMINARY  REPORT 

At  the  meeting  of  The  Johns  Hopkins  Hospital  Medical  Society,  on 
March  20,  1905,  a  brief  preliminary  report  -was  made  of  the  results  of  a 
large  number  of  experiments  performed  in  the  past  year  by  Dr.  Sowers  and 
myself  upon  the  abdominal  aorta  and  other  large  blood  vessels  of  dogs. 

It  had  occurred  to  one  of  us  that  possibly  the  aorta  might  be  successfully 
occluded  in  man  if  the  operations  were  undertaken  in  several  acts  instead 
of  one.  The  notion  of  gradual  compression  in  the  ordinary  use  of  the  term 
was  entertained  only  to  be  definitely  discarded  because  of  the  seemingly 
insurmountable  difficulty  of  preserving  asepsis.  A  sinus  must  form  about 
any  instrument  leading  from  the  aorta  to  the  air,  and,  sooner  or  later,  such 
a  sinus  necessarily  becomes  infected.  The  method,  therefore,  should,  we 
thought,  be  one  permitting,  in  each  entr'acte,  complete  closure  of  the  wound ; 
the  apparatus  or  material  to  be  applied  to  the  aorta  should  not  be  bulky  nor 
endanger,  by  its  form  or  substance,  the  adjacent  parts ;  and  it  should  admit 
of  easy  readjustment  at  subsequent  operations.  Metal  bands  of  silver  and 
aluminum  were  employed  with  the  belief  that  at  each  operation  the  amount 
of  constriction  could  be  regulated  to  a  nicety.  With  the  aid  of  a  clever 
jeweler  an  instrument  was  devised  to  curl  the  metal  strip,  in  situ,  in  perfect 
cylinder-form,  about  the  vessel.  The  tightening  of  the  band,  the  cylindrical 
form  being  preserved  with  great  care,  was  completed  with  fingers  and  tweez- 
ers, but  ultimately,  when  narrower  bands  were  used,  the  tweezers  could, 
fortunately,  be  discarded.  The  instrument  for  curling  the  band  was  also  in 
the  majority  of  cases  finally  dispensed  with. 

We  attempted  rather  persistently  but  unsuccessfully  to  determine  accu- 
rately the  blood  pressure  in  the  femoral  arteries  during  and  after  the  appli- 
cation of  the  band;  and  Dr.  Haller  is  now  devising  and  constructing  for  us 
an  instrument  on  the  principle  of  the  Erlanger  instrument  to  enable  one 
to  determine  the  blood  pressure  in  small  and  large  arteries  without  dividing 
them.  Calculations,  therefore,  as  to  the  amount  of  occlusion  were  roughly 
determined  by  the  fingers  on  the  aorta  and  femorals. 

Presented    before   The   Johns    Hopkins    Hospital    Medical    Society,    Baltimore, 
March  20.  1905. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1905,  xvi.  346-347. 
314 


PARTIAL  OCCLUSION  OF  BLOOD  VESSELS  315 

For  some  weeks  we  feared  that  the  sharp  edges  of  the  bands  would  cut 
through  the  pulsating  and  constricted  aorta,  and  considered  several  methods 
to  obviate,  if  necessary,  this  danger.  On  the  twelfth  day  of  the  operation 
a  dog  died  from  haemorrhage,  the  result  of  ulceration  at  the  upper  edge  of 
the  band  and  we  feared  that  the  procedure  might  be  doomed;  but  no 
further  cases  of  haemorrhage  occurring,  we  resumed,  in  a  few  weeks,  the 
experiments.  Then,  after  about  3  months,  investigating  in  several  dogs  the 
conditions  at  the  site  of  the  band,  we  found,  to  our  chagrin,  that  just  as  we 
had  feared,  the  wall  of  the  aorta  embraced  by  the  band  was,  in  almost  every 
instance,  atrophied,  being  reduced  in  some  cases  to  hardly  more  than  a 
film  in  thickness.  Notwithstanding  this  observation  the  experiments  went 
on  uninterruptedly,  a  new  series  being  instituted  with  the  hope  that,  with 
an  improved  technique  and  the  employment  of  narrower  and  thinner  bands, 
the  walls  of  the  arteries  might  retain  their  vitality,  at  least  for  a  time  suffi- 
ciently long  to  justify  a  second  interference,  and  possibly  the  complete  in- 
terruption of  the  blood  current  at  a  point  just  above  the  band.  The  width 
of  the  bands  was  reduced  from  4  or  5  mm.  to  2  or  3  mm.,  and  the  thickness 
from  32  and  33  degrees  of  fineness  to  beyond  the  highest  numbers  of  our 
sheet  metal  scale,  to  what  we  term  Nos.  37,  38,  39,  and  40.  On  the  carotids 
and  femorals  metal  still  thinner  might  perhaps  be  used.  Bands  so  narrow 
and  so  very  thin  are  easily  rolled  with  the  fingers.  It  is  well  to  give  the  band 
approximately  the  proper  curling  before  placing  it  on  the  artery.  From  the 
very  first  experiment  we  endeavored  in  each  instance  to  roll  the  band  as 
perfectly,  as  cylindrically,  as  possible,  flattening  of  it  being  studiously 
guarded  against  for  obvious  reasons.  Attempts  to  diminish  the  blood  pres- 
sure very  gradually  and  with  accuracy  are,  of  course,  made  futile  by  an 
imperfection  in  the  rolling  of  the  band.  A  flattening  or  imperfectly  rolled 
band  might,  even  if  loosely  applied,  injure  the  intima  and  so  cause  throm- 
bosis and  completely  interrupt  the  circulation.  For  these  and  other  reasons 
silver  wire,  which  was  tried,  was  found  impracticable.  About  ninety  experi- 
ments were  made  on  sixty-eight  dogs.  The  technique  of  our  operating  rooms 
at  The  Johns  Hopkins  Hospital  was  observed  in  every  particular  and  hence 
much  time  was  consumed  by  the  operations ;  but  we  are  well  repaid  for  the 
care  exercised  by  the  absence  of  wound  infection.  The  buried,  continuous, 
silver  wire  suture  of  the  skin,  and  rubber  gloves  for  operator  and  assistants 
seem  invaluable  in  experimental  surgery  when  wound  infection  must  be 
avoided.  We  are  greatly  indebted  to  Messrs.  Cowles,  Faris,  Haller,  Lank- 
ford,  and  other  fourth  year  students  for  their  faithful  assistance  and  interest 
and  useful  suggestions. 


316  PAETIAL  OCCLUSION"  OF  BLOOD  VESSELS 

SlJMMAEY. 

(1)  Thrombosis  has  not  been  observed  in  a  single  case.  In  a  few  of  the 
specimens,  however,  proximal  to  the  band,  in  the  occluded  artery,  a  little 
caruncle-like  body,  suggesting  the  substitution  of  a  minute  clot,  has  been 
present. 

(2)  Applied  tightly  enough  to  completely  interrupt  the  circulation,  the 
band  has  caused  atrophy  and  sometimes  complete  absorption  of  the  aortic 
wall;  in  such  cases  haemorrhage  has  invariably  been  prevented  by  the 
formation  of  connective  tissue. 

(3)  "With  two  or  three  exceptions  there  has  been  no  evidence  of  adhesion 
of  the  folded  intima  under  the  band;  aortic  walls  folded  on  themselves  so 
snugly  that,  the  band  being  still  in  place,  water  could  not  be  forced  through 
with  a  syringe,  could  easily  be  smoothed  out  and  the  full  lumen  reestab- 
lished on  removal  of  the  band. 

(4)  Less  snugly,  loosely,  and  very  loosely  applied  bands  may  remain  on 
the  aorta,  femorals  and  carotids  for  months  without  causing  macroscopic 
injury  to  the  walls  of  the  artery.  In  experiments  of  this  variety  the  band 
after,  say,  one  hundred  days,  shimmers  brightly  under  a  normal  looking 
peritonaeum,  causing  no  visible  reaction,  and  it  may  be  as  easily  removed 
from  the  aortic  wall  as  when  originally  applied.  The  probe  point  of  a  fine 
scissors  passed  into  the  lumen  of  the  aorta  and  thus  on  through  the  band, 
dividing  it  and  the  aortic  wall,  reveals  a  perfectly  normal  looking  intima 
and  an  aortic  wall  which,  on  gross  section,  evidences  no  change  in  texture 
and  usually  none  in  color. 

"We  are  encouraged  to  believe  that  there  may  be  a  place  in  surgery  for  the 
partially  occluding  band.  Eecently  we  have  twice  had  occasion  to  use  it  on 
the  human  subject. 

Case  I. — To  the  left  common  carotid  was  applied  an  aluminum  land 
which  almost  occluded  it. — Even  in  this  case  slight  head  symptoms  persisted 
for  several  months,  making  it  seem  likely  that  complete  occlusion  would 
have  been  followed  by  severe  symptoms  if  not  by  death.  We  regretted  that, 
in  this  case,  the  band  was  inadvertently  rolled  tighter  than  intended;  it 
could,  of  course,  have  easily  been  removed  and  reapplied,  but  our  notions 
being  rather  vague  as  to  the  precise  amount  of  constriction  which  we  desired 
and  being  unable  to  determine  accurately  the  blood  pressure  distal  to  the 
band,  we  decided  to  let  it  remain  and  note  the  results. 

Case  II. — A  woman  asphyxiated  to  unconsciousness  by  an  aneurism  of 
the  arch  of  the  aorta. — She  was  restored  to  consciousness  and  temporary 
relief  afforded  by  a  tube  passed  into  the  right  bronchus.  The  skiagraph 
seeming  to  indicate  that  the  aneurism  was  chiefly  on  the  left  side  of  the 
sternum  and  the  condition  of  the  patient  being  so  desperate,  I  decided,  hav- 
ing watched  her  for  nearly  half  a  day,  that  she  would  live  only  a  few  hours 


PARTIAL  OCCLUSION  OF  BLOOD  VESSELS  317 

unless  surgery  could  assist  her.  We  exposed  carefully  and  freely,  without 
opening  either  pleural  cavity,  the  heart,  the  arch  of  the  aorta  and  the  large 
vessels  at  the  root  of  the  neck,  hoping  possibly  to  be  able  to  encircle  the 
aortic  arch  with  a  band  of  metal  between  the  origins  of  the  innominate  and 
left  carotid  arteries;  but  the  aneurism  involved  the  entire  arch  and  thus 
defeated  our  very  earnest  efforts  to  carry  out  the  plan.  The  patient  suc- 
cumbed on  the  operating  table  before  we  had  entirely  despaired  of  being 
able  to  do  something  for  her  relief,  and  while  we  were  still  endeavoring  to 
make  a  path  for  the  band. 

The  small  arteries,  the  ligation  of  which  endangers  merely  the  life  of  the 
limb  may  prove  as  suitable  for  partial  occlusion  as  the  aorta  (abdominal  and 
thoracic)  which  has  never  been  successfully  ligated  in  man.  Meagre  as  our 
knowledge  of  this  subject  is,  I  should  probably  feel  it  my  duty  to  test  the 
value  of  partial  rather  than  resort  to  complete  occlusion  of  the  aorta,  com- 
mon carotid,  popliteal  and  other  arteries  whose  ligation  is  attended  with 
great  danger  to  life  or  limb. 

The  partial  occlusion  of  arteries  discloses  a  suggestive  and,  I  believe,  a 
promising  field  for  investigation  in  physiology  and  experimental  pathology. 

The  history  of  the  subject  will  be  considered  in  a  subsequent  article.  Of 
particular  interest  to  us  is  the  discovery  that  Luigi  Porta,  about  1846, 
attempted  partial  occlusion  of  arteries  by  means  of  strips  of  diachylon  plas- 
ter applied  in  a  way  similar  to  that  described  by  Brewer,  who  so  ingeniously 
and  cleverly  closes  wounds  of  arteries  by  strapping  them  with  an  absorbable 
plaster. 


THE  EESULTS  OF  THE  COMPLETE  AND  INCOMPLETE 

OCCLUSION  OF  THE  ABDOMINAL  AND  THORACIC 

AORTAS  BY  METAL  BANDS  * 

With  the  assistance  of  my  house  surgeon,  Dr.  TV.  F.  M.  Sowers,  who  most 
zealously  aided  me  in  making  the  experiments,  and  Dr.  E.  H.  Richardson, 
a  member  of  the  surgical  staff  of  The  Johns  Hopkins  Hospital,  during  the 
past  twelve  months,  I  have  been  able  to  conduct  experiments  on  the  aortas 
of  more  than  one  hundred  dogs  and  have  noted  particularly : 

1.  The  effects  of  occlusion,  partial  and  complete,  immediate,  mediate  and 
ultimate  on  the  blood  pressure,  general  and  local  (above  and  below  the 
band).  The  pressure  below  the  band  is  lowered  in  proportion,  roughly,  to 
the  amount  of  occlusion.  The  return  of  the  pressure  to  approximately 
normal  below  the  band  is  rapid,  but  varies  greatly  in  the  different  dogs. 
For  example,  in  one  dog,  a  rise  below  the  band  of  ten  millimetres  (Hg 
manometer)  was  noted  in  ten  minutes;  whereas,  in  another,  two  hours  were 
required  for  a  rise  of  fifteen  millimetres.  For  the  return  of  the  normal  pulse 
wave  months  may  be  required. 

2.  The  macroscopic  and  microscopic  findings  in  the  arterial  wall,  (a)  Par- 
tially occluding  bands  produced,  as  a  rule,  no  macroscopic  change  in  the 
aortic  wall  under  the  band,  even  after  seven  or  eight  months,  (b)  Under 
completely  occluding  bands  the  wall  usually  atrophied,  and  in  the  course 
of  weeks  or  months  was  absorbed,  (c)  IVhen  the  lumen  is  almost  but  not 
quite  occluded,  complete  occlusion  may  result  spontaneously  with  the  con- 
version of  the  arterial  wall  embraced  by  the  band  into  a  solid  cylinder  of 
living  tissue.  This  may  be  considered  the  ideal  closure  of  an  artery,  and 
hitherto  has  probably  not  been  achieved.  Although  this  spontaneous  secon- 
dary occlusion  has  occurred  only  thrice  in  the  long  series  of  experiments,  it 
might,  perhaps,  if  systematically  tried  for,  be  accomplished  frequently,  and 
ultimately  the  band  might  be  so  accurately  applied  that,  unaided  further  by 
the  surgeon,  a  partial  occlusion  would  be  likely  to  proceed  to  total  occlusion. 

1  Abstract  of  remarks  before  the  Section  on  Surgery  and  Anatomy  of  the  American 
Medical  Association,  Boston,  June  5-8,  1906.  [Dr.  Halsted  prefaced  his  remarks 
with  a  brief  historical  sketch  of  the  results  of  ligation  of  the  abdominal  aorta  in 
animals  and  man  and  demonstrated  an  instrument  and  the  method  employed  in  the 
application  of  the  metal  (aluminum)  bands.] 

Tr.  Surg,  and  Anat.  Am.  M.  Ass.,  Chicago,  1906,  587-590. 

Also:   J.  Am.  M.  Ass.,  Chicago,  1906,  xlvii,  2147. 
318 


ABDOMINAL  AND  THOEACIC  AORTAS  319 

3.  The  effects  on  the  spinal  cord  and  its  coverings.  The  study  of  the  spinal 
cord  was  entrusted  to  Mr.  P.  K.  Gilman  (now  Dr.  Gilman  and  a  member 
of  my  staff),  whose  trained  eye  discovered  in  a  number  of  cases,  about  three 
months  after  operation,  a  deposit  of  extradural  fat  about  the  cord  below 
the  site  of  the  aortic  band.  In  three  cases  the  production  of  fat  was  so  great 
that  it  filled,  seemingly  under  considerable  tension,  the  vertebral  canal. 
This  is  a  phenomenal  discovery  and  one  which  signifies  much,  whether  on 
further  investigation  it  be  found  that  lesions  in  the  spinal  cord  or  simple 
anaemia  of  the  particular  extradural  region  is  responsible  for  the  deposition 
of  fat.  It  is  important  to  determine  with  precision  the  limitations  of  the 
fat  deposit  and  to  ascertain  if  regions  at  a  distance,  supplied  by  nerves 
derived  from  the  affected  cord-area,  yield  symmetrical  masses  of  fat. 

As  to  the  practical  value  of  the  occlusion  of  blood  vessels  by  the  metal 
band,  I  have  in  mind  the  gradual  occlusion  of  large  arteries,  particularly 
the  aorta,  abdominal  and  thoracic.  A  vessel  partly  closed  by  a  nicely  rolled 
band  may  subsequently  be  completely  occluded  either  spontaneously  (ideal 
result)  or  by  the  pressure  of  the  fingers  or  of  a  forceps  on  the  band.  It  is 
conceivable  that  in  some  instances  this  subsequent  tightening  of  the  band 
might  be  accomplished  subcutaneously,  but  usually  a  second,  though  com- 
paratively insignificant,  operation  would  be  required.  Aortic  aneurisms  if 
situated  too  high  for  the  subdiaphragmatic  application  of  the  band  might 
be  cured  by  a  band  on  the  thoracic  aorta.  To  apply  a  band  to  the  thoracic 
aorta  is  not  difficult  and  may  be  executed  rapidly  without  the  excision  of  a 
rib.  When  it  may  be  necessary  to  test  the  effect  of  blocking  an  artery  before 
permanently  occluding  it,  as  in  carotid,  popliteal  and  high  femoral  ligations, 
the  metal  band  might  be  desirable  because  (1)  it  serves  the  purpose  of  both 
clamp  and  ligature;  (2)  during  the  operation  it  may  be  safely  removed  if 
advisable,  for  the  arterial  wall  is  uninjured  by  it;  (3)  if  too  tightly  rolled 
it  may  be  removed  at  any  time  after  the  operation,  even  days  thereafter,  in 
case  gangrene  threatened  or  cerebral  symptoms  developed  for,  the  arterial 
wall  being  uninjured,  the  normal  lumen  remains. 

I  have  at  present  under  observation  a  dog  whose  thoracic  aorta  has  been 
experimentally  occluded.  The  aluminum  band  was  not  rolled  so  tightly  as 
completely  to  occlude  the  artery  or  to  produce  demonstrable  weakness  of 
the  hind  legs.  The  recovery  from  the  operation  was  uneventful,  but  about 
three  weeks  thereafter  paraplegia  developed  suddenly  and,  coincidentally, 
disappearance  of  the  femoral  pulse  on  both  sides.  I  expect  to  find  that  com- 
plete occlusion  of  the  thoracic  aorta  has  been  spontaneously  accomplished, 
and  in  the  manner  above  described.  Partial  occlusion,  not  becoming  com- 
plete, might  of  itself  occasionally  cure  an  aneurism. 


320  OCCLUSION  BY  METAL  BANDS 

In  the  human  subject  I  have  partially  occluded  the  innominate  once  and 
the  common  carotid  four  times,  successfully,  with  the  aluminum  band.  In  a 
case  of  large  popliteal  aneurism  I  employed  the  metal  band  to  occlude  com- 
pletely the  femoral  artery  because  this  method  enabled  me  particularly  well 
to  test  the  blood  pressure  during  the  gradual  process  of  occlusion.  In  the 
case  of  a  woman  asphyxiated  to  unconsciousness  by  an  aneurism  of  the  aortic 
arch  I  exposed,  carefully  and  freely  and  without  puncturing  either  pleural 
cavity,  the  heart  and  arch  of  the  aorta,  hoping  possibly  to  be  able  to  encircle 
with  a  band  the  aortic  arch  between  the  regions  of  the  innominate  and  left 
carotid  arteries,  but  the  aneurism  so  involved  the  entire  arch  as  to  defeat 
the  earnest  endeavor  to  execute  the  procedure. 

I  may  assume  that  it  is  not  necessary  to  remind  this  audience  of  the  re- 
sults which  have  attended  ligation  of  the  human  aorta.  The  most  success- 
ful of  these  operations  was  performed  in  1899  by  Dr.  W.  W.  Keen,  whose 
patient,  the  thirteenth  case,  lived  forty-three  days. 


CLINICAL  AND  EXPERIMENTAL  CONTRIBUTIONS  TO  THE 
SURGERY  OF  THE  THORAX1 

The  Thoracic  Aorta. — December  18,  1906,  Dr.  Halsted  applied  a  partially 
occluding  aluminum  band  to  the  thoracic  aorta  about  7  cm.  above  the  dia- 
phragm, with  the  hope  of  influencing  the  progress  of  and  relieving  the  ex- 
cruciating pain  caused  by  a  large  aneurism  of  the  upper  abdominal  aorta. 
A  positive  pressure  box  designed  by  Drs.  Follis  and  Fisher  was  satisfactorily 
employed.  Convalescence  from  the  operation  was  without  noteworthy  inci- 
dent. The  pain,  which  had  been  almost  agonizing  before  the  operation, 
was  so  fully  relieved  that  on  the  second  day  thereafter  and  for  the  fourteen 
following  days  1/10  to  1/12  of  a  grain  of  morphine,  given  twice  in  twenty- 
four  hours,  sufficed  to  relieve  the  craving  for  the  drug  as  well  as  the  slight 
pain  of  which  the  patient  complained.  The  chief  postoperative  disturbances 
were  digestive.  January  10,  1907,  an  aluminum  band  was  applied  to  the 
abdominal  aorta,  below  the  aneurism  and  the  inferior  mesenteric  artery, 
just  tight  enough  to  occlude  the  femoral  pulse.  From  the  second  operation 
the  patient  recovered,  also  uneventfully.  January  23d  dysphagia  developed, 
and  a  distinct  pulsation  was  observed  in  the  third  and  fourth  intercostal 
spaces.  January  28th  patient  died  from  intrathoracic  rupture  of  the 
aneurism.  The  aortic  wall  under  the  bands,  thoracic  and  abdominal,  ap- 
peared normal.  Interesting  observations  of  the  urine  and  blood  pressures, 
in  this  and  the  following  case,  were  made  by  Dr.  Gatch  and  will  be  reported 
by  him. 

That  there  is  reason  for  hope  of  cure  in  cases  of  aneurism  of  the  abdomi- 
nal aorta  by  partial  constriction  of  this  vessel,  even  when  the  band  must  be 
applied  above  the  renal  arteries,  the  following  case  would  seem  to  indicate. 

The  Abdominal  Aorta. — February  23,  1909,  Dr.  Halsted  applied  in  the 
human  subject  an  aluminum  band  to  the  abdominal  aorta,  between  the 
superior  mesenteric  for  an  aortic  aneurism  extending  from  its  bifurcation 
to  the  renal  arteries.  The  aorta  having  been  exposed,  its  isolation  at  the 
required  spot,  just  above  the  almost  vertical  edge  of  the  aneurism,  was 
accomplished  with  great  difficulty.  The  inferior  mesenteric  vein  was  tensely 
stretched  along  the  left  edge  of  the  aorta  at  the  site  of  election.  The  renal 
arteries  below,  the  left  renal  vein  in  front,  the  superior  mesenteric  artery 

1  Presented  at  the  American  Surgical  Association,  Philadelphia,  June  3-5,  1909. 
Tr.  Am.  Surg.  Ass.,  Phila.,  1909,  xxvii,  111-115. 

22  321 


322  METAL  BANDS  ON 

above,  and  the  inferior  mesenteric  vein  to  the  left,  when  separated  in  grid- 
iron form,  exposed  barely  sufficient  space  on  the  aorta  for  the  occupancy  of 
a  narrow  metal  band.  The  greatly  emaciated  patient  was  promptly  relieved 
of  the  aneurismal  pain  by  the  operation.  The  tumor  steadily  decreased  in 
size  for  five  days.  On  March  1st,  the  sixth  day  after  operation,  the  aneurism, 
which  prior  to  operation  projected  and  pulsated  conspicuously,  had  disap- 
peared to  inspection,  and  on  palpation  the  force  of  the  pulsation  seemed  less 
than  over  the  normal  aorta  above.  The  patient,  a  physician,  aged  fifty-three 
years,  was  on  this  and  the  preceding  day,  unable  either  to  appreciate  the 
presence  of  the  aneurism  by  his  sensations  or  to  locate  it  by  the  sense  of 
touch,  and  expressed  the  belief  that  he  was  cured.  The  following  day  a 
definite  increase  in  the  size  of  the  aneurism  and  in  the  force  of  the  pulsa- 
tion was  observed.  In  two  days  it  was  as  large  and  in  three  or  four  days 
larger  than  before  the  application  of  the  band.  March  5th  patient  had  a 
sudden  onset  of  pain  in  the  right  iliac  fossa  and  about  the  umbilicus,  a  chill, 
and  a  temperature  of  103°.  The  rate  of  enlargement  of  the  aneurism  in- 
creasing, March  12th  Dr.  Finney  wired  the  aneurism  by  his  method  with 
success  as  concerned  the  hardening  of  the  aneurism;  but  it  continued  to 
grow  with  even  greater  rapidity.  The  patient,  unable  to  take  food,  died 
April  11,  1909.  At  the  autopsy  the  aneurism,  larger  than  a  cocoanut,  was 
found  to  be  remarkably  well  solidified  in  consequence  of  the  wiring,  except 
posteriorly  and  above.  The  band  was  in  place  and  the  tissues  about  it  were 
quite  normal  in  appearance.  Ultimately  a  small  psoas  abscess  which  had 
softened  the  underlying  vertebrae  and  the  posterior  wall  of  the  overlying 
aneurism  was  discovered,  and  from  it  a  fine  sinus  was  traced  exactly  to  the 
lower  edge  of  the  aluminum  band  on  the  aorta.  The  suppuration,  the  first 
in  the  annals  of  The  Johns  Hopkins  Hospital  in  a  clean  abdominal  case, 
was,  in  the  opinion  of  Dr.  Halsted,  the  cause  of  the  sudden  enlargement  of 
the  aneurism  after  its  apparent  disappearance.  The  aortic  wall  under  the 
band  was  macroscopically  normal  notwithstanding  the  infection.  The  growth 
of  the  aneurism  in  the  upward  or  centripetal  direction  had  been  abruptly 
held  in  check  by  the  band,  which  at  its  upper  edge  was  in  contact  with  the 
superior  mesenteric  artery,  and  at  its  lower  with  both  renal  arteries.  Distress- 
ing as  was  the  outcome  in  this  instance,  one  finds  much  encouragement  in 
this  case  for  continuing  the  endeavor  to  cure  aneurism  of  the  aorta  by  par- 
tial occlusion  of  this  vessel  after  the  manner  described. 

The  Lungs. — In  the  experimental  surgery  of  the  lungs  upon  dogs 
Dr.  Halsted,  assisted  always  by  Dr.  Gatch  and  Messrs.  Emmert  and  Webb, 
concerned  himself  chiefly  witli  the  bronchi  and  vessels  at  the  root  of  the 
lungs  and  the  various  lobes.  Occlusion  of  the  main,  the  primary,  and  second- 
ary divisions  of  the  bronchi  was  practised,  various  methods  and  almost 


ABDOMINAL  AND  THOEACIC  AOKTAS  323 

all  degrees  of  occlusion  being  tested.  The  lung  was  only  occasionally  excised. 
From  complete  occlusion  of  a  bronchus  by  ligature  or  metal  band  there 
resulted  atalectasis,  with  no  apparent  impairment  of  the  health  of  the  dog. 
Occlusions  by  the  metal  band  of  primary  or  secondary  bronchi,  so  nearly 
complete  as  hardly  to  permit  the  passage  of  a  very  fine  knitting  needle  and 
as  to  cause  circumscribed  areas  of  atalectasis,  in  no  instance  gave  rise  to 
pulmonary  emphysema  or  to  definite  dilatation  of  a  bronchus.  Under  com- 
pletely or  partially  obliterating  bands  the  mucous  lining  of  the  bronchus 
under  the  band  was  always  found  unaffected  even  after  several  weeks.  In 
no  instance  had  the  experimenters  been  able  to  crush  the  bronchial  wall 
with  the  encircling  band,  and  hence  in  no  case  had  obliteration  of  the  bron- 
chus occurred  by  this  method.  Even  ligatures  of  black  silk  which  com- 
pletely occluded  the  bronchus  did  not  permanently  obliterate  it  unless  the 
mucosa  were  crushed.  Particularly  secure  obliteration  was  accomplished  by 
bisection  of  the  bronchus,  careful  excision  with  the  scalpel  of  its  mucosa,  and 
the  approximation  of  the  raw  surfaces  by  a  running  suture  of  fine  black 
silk.2  By  this  method  the  bronchus  may  be  converted  into  a  solid  fibrous  cord. 
Inversion  of  the  bronchus  was  abandoned  in  the  two  cases  in  which  it  was 
attempted  because  the  bronchus  seemed  too  short  for  nice  adjustment. 

Ligation  of  the  pulmonary  arteries  or  veins  to  the  lobes  of  one  side  pro- 
duced no  visible  change  in  the  color  or  consistence  of  the  lobes  during  the 
period  of  operation.8  About  a  week  later,  however,  in  the  two  observations 
of  this  kind,  a  slight  change  in  the  color  and  apparently  in  the  consistence 
of  the  lobes  so  treated  was  noted.  They  were  less  pink,  a  little  grayer,  and 
possibly  a  little  less  aerated  than  the  other  lobes.  Attempts  to  inoculate  the 
lungs  of  dogs  with  tuberculosis  were  uniformly  and  rather  unexpectedly 
successful  (3  cases).  Ligation  of  the  pulmonary  vessels,  undertaken  with 
the  idea  that  possibly  the  infection  might  thereby  be  intensified  or  modified, 
was  without  demonstrable  influence. 

The  Technique. — In  addition  to  the  usual  precautions  against  infection, 
such  as  gloves  and  masks,  and  unusual  care  in  the  shaving  and  preparation 
of  the  skin  of  the  dogs,  a  thin  covering  of  an  alcoholic  solution  of  shellac 
was  applied  to  the  shaved  area  over  a  single  layer  of  gauze.  Some  ten  or  more 
years  ago  Dr.  Halsted  experimented  with  shellac  solutions  as  covering  for 
the  hands  of  the  operator,  with  the  idea  that  possibly  under  certain  circum- 
stances the  rubber  gloves,  which  since  1890  had  been  used  in  his  clinic  at 
The  Johns  Hopkins  Hospital,  might  be  dispensed  with,  but  he  soon  aban- 
doned the  notion  that  a  film  of  shellac  or  other  substance  applied  to  the 

2  After  the  manner  devised  by  Dr.  Halsted  for  the  closure  of  the  duct  of  the 
gallbladder. 

3  These  observations  confirm  those  of  Lichtheim,  Welch,  and  subsequent  observers. 


324    METAL  BANDS  ON  ABDOMINAL  AND  THOEACIC  AOKTAS 

hands  might  replace  the  gloves.  For  the  skin  of  the  human  patient  the  shel- 
lac has  since  then  been  occasionally  but  not  enthusiastically  employed.  Very 
small  skin  and  pleural  incisions  were  made,  the  ribs  being  forcibly  separated 
with  the  fingers  and  then  with  the  retractor.  The  ribs  were  brought  to- 
gether with  silver  wire,  and  the  soft  parts  sewed  with  fine  black  silk.  All 
sutures  were  buried  except  the  so-designated  epithelial  stitch,  elsewhere 
described,  which  rubs  away  without  attention  from  the  surgeon,  or  may  be 
ripped  off  like  a  plaster  from  the  surface.  This  stitch,  which  to  human  sur- 
gery has  only  occasional  application,  is  useful  in  the  surgery  of  dogs. 

In  twenty-one  consecutive  thoracotomies  there  was  only  one  primary 
infection  of  the  thorax,  and  in  this  case  no  masks  were  used  and  a  droplet 
contamination  of  the  wound  was  noted  in  the  account  of  the  operation  writ- 
ten immediately.  Positive  pressure  was  employed  in  all  of  the  experiments, 
and  by  means  of  a  very  simple,  effective,  and  very  cheap  apparatus  devised 
by  Dr.  Gatch.  The  cost  of  the  box  was  ten  dollars.  It  was  exhibited  to  the 
Association. 


PAETIAL  OCCLUSION  OF  LAEGE  AETEEIES  BY 
ALUMINUM  BANDS  a 

The  paper  of  Dr.  Matas  has  interested  me  exceedingly.  I  regret  that  I 
had  not  known  of  the  Moszkowicz  test  in  time  to  make  use  of  it  in  a  case 
operated  upon  at  The  Johns  Hopkins  Hospital  last  winter.  In  the  removal 
of  a  cystic  sarcoma  from  the  popliteal  space  it  was  necessary  to  excise  almost 
the  entire  popliteal  artery  and  vein,  and  what,  at  the  time,  seemed  to  be  the 
entire  sciatic  nerve.  Inasmuch  as  gangrene  has  almost  invariably  supervened 
upon  excision  so  complete  of  both  popliteal  vessels,  about  ten  inches  of  the 
internal  saphenous  vein  of  the  opposite  thigh  was  transplanted  by  the  Carrel 
method;  its  upper  end  was  sutured  to  the  proximal  stump  of  the  popliteal 
artery  in  Hunter's  canal,  and  its  lower  end  to  the  distal  stump  of  the  pop- 
liteal vein.  Blood  circulated  freely  through  the  transplanted  piece  for  about 
thirty  minutes ;  then  thrombosis  of  its  lower  end  occurred.  The  temperature 
of  the  foot  on  the  operated  side  was  higher  than  that  of  the  other  foot  for 
several  days.  Gangrene  did  not  occur,  notwithstanding  the  removal  of  the 
popliteal  artery  and  vein  down  almost  to  the  point  of  division  of  the  former. 

As  to  the  relative  ease  with  which  the  flattened  bands  recommended  by 
Dr.  Matas  can  be  made  use  of,  the  idea  evidently  prevails  that  the  applica- 
tion of  the  rolled  bands  with  the  band-curler  is  difficult.  One  must,  of 
course,  have  some  notion  as  to  the  thickness,  width,  and  length  of  the  metal 
strip,  which  may,  in  a  given  case,  be  employed  to  the  best  advantage.  With 
suitable  instruction  one  might,  I  believe,  after  practising  an  hour  or  two  on 
an  animal,  become  quite  proficient,  and  be  able  to  apply  the  bands  properly 
rolled  in  a  cylindrical  form  as  readity,  if  not  indeed  as  quickly,  as  the  flat- 
tened strips. 

We  learned  in  the  course  of  experiments  made  with  the  object  of  pre- 
serving the  integrity  of  the  wall  of  the  artery,  that  accurate  rolling  of  the 
band,  viz.,  with  preservation  of  cylindrical  form  is  essential.  When  the 
band  is  properly  rolled  the  wall  of  the  artery  is  so  infolded  that  pressure  on 
no  point  of  the  arterial  wall  is  excessive,  and  hence  perceptible  thinning  and 
weakening  of  the  wall  does  not  occur,  at  least  for  many  months,  unless  the 

1  Remarks  in  discussion  of  Dr.  Rudolph  Matas'  paper,  "  Some  of  the  problems 
related  to  the  surgery  of  the  vascular  system :  testing  the  efficiency  of  the  collateral 
circulation  as  a  preliminary  to  the  occlusion  of  the  great  surgical  arteries."  American 
Surgical  Association,  Washington,  D.  C,  May  3-5,  1910. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1910,  xxviii,  49-52. 

325 


326  PARTIAL  OCCLUSION  OF  ARTERIES 

constriction  has  been  made  so  tight  as  to  shut  off  the  arterial  flow  within  the 
lumen  of  the  banded  vessel,  and  presumably,  also,  the  blood  current  in  the 
vasa  vasoruni.  Occasionally  the  compression  has  been  accomplished  with 
such  nicety  that  the  constricted  portion  of  the  artery,  the  part  circum- 
scribed by  the  metal,  became  converted  into  a  fibrous  band.  It  need  hardly 
be  emphasized  that  it  is  desirable  that  the  vitality  of  the  arterial  wall  should 
not  be  impaired  whether  the  band  is  permanently  or  temporarily  applied. 

I  am  pleased  to  be  able  to  report  two  cases  of  probable  cure  of  aneurism — 
one  subclavian  and  one  external  iliac — by  partial  obliteration,  in  the  former 
case  of  the  subclavian,  and  in  the  latter  of  the  common  iliac  artery. 

I  am  not  sure  that  aneurisms  curable  by  simple  ligation  of  an  artery 
might  not  be  cured  as  surely  and  promptly  by  incomplete  occlusion  of  the 
vessel — by  an  occlusion  sufficient  to  stop  the  pulsation  in  the  constricted 
artery,  but  not  enough  to  arrest  entirely  the  flow  of  blood  through  the  almost 
obliterated  portion. 

Before  making  more  definite  pronouncement  on  this  matter  further  ex- 
periments must  be  made  in  testing  on  normal  vessels  the  rapidity  of  the 
return  circulation  under  the  two  conditions. 

Writers  on  the  subject  of  ligation  of  the  common  iliac  artery  are  agreed 
that  this  operation  is  followed  by  gangrene  in  from  20  per  cent  to  33  per 
cent  of  the  cases.  Inasmuch  as  gangrene  has  never  resulted  from  ligation 
of  the  abdominal  aorta  in  the  human  subject,  not  in  any  one  of  the  many 
instances  in  which  I  have  occluded  this  vessel  in  dogs,  it  is  difficult  to  be- 
lieve that  it  is  so  likely  to  occur  after  ligation  of  one  common  iliac  artery. 
And,  having  studied  carefully  the  histories  of  the  cases  in  which  gangrene 
is  reported  to  have  occurred  after  ligation  of  a  common  iliac  artery,  I  find 
that  in  not  a  single  instance  is  the  gangrene  to  be  attributed  to  the  ligation 
of  this  vessel  alone.  In  every  case  other  important  vessels  concerned  in 
the  establishment  of  the  anastomotic  circulation  were  ligated ;  in  some  cases 
almost  every  named  vessel  which  could  contribute  to  the  restoration  of  the 
circulation  was  ligated,  and  in  many  of  the  cases  wound  infection  was  an 
additional  and  occasionally  very  considerable  complication. 

I  regret  that  I  have  as  yet  no  case  to  report  of  cure  of  an  aortic  aneurism, 
but  I  find  great  encouragement  to  further  attempts  from  the  result  of  the 
only  case  suitable  for  the  application  of  a  band  to  the  abdominal  aorta 
which  it  has  been  my  fortune  to  treat.  In  this  case  the  aneurism  was 
spheroidal  and  about  10  or  11  cm.  in  diameter.  It  was  found  on  operation 
to  extend  to  the  renal  arteries.  Very  great  difficulty  was  experienced  in 
dug  enough  of  the  aorta  between  the  renal  arteries  and  the  coeliac  axis 
to  permit  of  the  passing  under  it  of  a  tape  as  a  preliminary  step  in  the 
application  of  the  metal  band.   The  inferior  mesenteric  vein  was  especially 


BY  ALUMINUM  BANDS  327 

in  the  way,  traversing  the  aorta  from  right  to  left  at  the  very  point  at  which 
the  band  had  to  be  applied.  The  renal  vessels,  arteries  and  veins,  stretched 
across  our  little  field  and  had  to  be  drawn  downward.  The  coeliac  axis  was 
above;  the  vena  cava,  which  overlay  the  aneurism  and  a  part  of  the  aorta 
between  the  renal  vessels  and  the  coeliac  axis,  could  be  dislocated  to  the 
right.  "We  were  working,  consequently,  in  a  little  gridiron-like  square, 
rigidly  bounded  on  all  sides  by  large  blood  vessels,  each  of  vital  importance. 
This  space,  stretched  to  its  utmost,  was  barely  large  enough  to  admit  ulti- 
mately two  fingers.  The  aorta  leading  to  the  aneurism,  which  proved  to  be 
of  the  sacculated  variety,  lay  very  deep  behind  the  almost  vertical  upper 
edge  of  the  tumor.  For  a  considerable  time  the  passage  of  a  ligature  at 
this,  the  only  feasible  point,  seemed  almost  beyond  accomplishment.  When, 
after  about  one  and  a  half  hours,  we  had  succeeded  in  passing  the  first  tape 
around  the  aorta  at  the  point  of  election,  just  above  the  renal  arteries  and 
close  to  the  aneurism,  the  placing  of  the  band  was  accomplished  with  rela- 
tively little  difficulty.  It  was,  however,  necessary  to  remove  the  glove  from 
my  left  hand  to  make  possible  the  rolling  of  the  band,  so  small  was  the  space 
and  so  deep  the  aorta. 

The  greatly  emaciated  patient  recovered  promptly  and  without  distress 
from  the  immediate  effects  of  the  operation.  The  following  day  he  expressed 
himself  as  greatly  relieved  of  the  pain  from  which  he  had  suffered  for  many 
months,  and  as  having  desire  for  food.  The  aneurism,  twenty -four  hours 
after  the  operation,  seemed  to  be  smaller.  In  forty-eight  hours  it  was  un- 
doubtedly smaller,  and  in  five  days  it  had  so  greatly  diminished  in  size  as 
to  be  almost  undemonstrable.  Then,  when  our  hopes  were  at  the  highest 
point,  the  patient  had  a  chill  and  temperature  of  about  40°  C.  On  the  fol- 
lowing day,  again  a  chill  and  high  temperature.  There  were  no  further  chills 
nor  elevations  of  temperature,  but  the  aneurism  enlarged  with  such  rapidity 
that  forty-eight  hours  after  the  first  chill  it  was  perhaps  as  large  as  before 
the  operation.  The  rate  of  enlargement  increased  with  the  passage  of  days. 
Dr.  Finney  was  asked  to  wire  the  aneurism.  This  he  successfully  accom- 
plished, but  the  growth  of  the  aneurism  was  apparently  not  influenced. 
Its  consistence  was,  however,  changed.  It  became  very  hard  at  first,  in  front, 
but  the  aneurism  was  evidently  expanding  from  behind.  Then  it  showed 
lateral  expansions  and  took  on  for  the  first  time  a  somewhat  lobulated  shape, 
being  softer  in  certain  portions.  In  a  few  weeks  the  patient  died,  chiefly 
of  starvation.  The  autopsy  revealed  what  was  the  probable  cause  of  the 
failure  of  the  operation  to  cure  the  aneurism,  but  not  until  the  abdominal 
contents,  including  the  aneurism,  had  been  removed.  A  small  psoas  abscess 
was  then  discovered,  containing  perhaps  three  or  four  ounces  of  very  thin 
seropus.    This  abscess  lay  directly  behind  the  aneurism  and  led  by  a  very 


328  PAKTIAL  OCCLUSION  OF  AKTEEIES 

small  sinus  to  the  site  of  the  band  on  the  aorta.  The  posterior  surface  of  the 
aneurism  had  evidently  been  softened  by  the  abscess  and.  hence,  deprived  of 
its  ability  to  resist  the  force  of  the  circulation,  had  rapidly  distended.  About 
the  coiled  wire  introduced  by  Dr.  Finney  there  was  a  large,  very  firm,  and 
more  or  less  organized  clot.  It  seemed  as  if  the  wiring  alone  might  have 
cured  the  aneurism  had  it  not  been  for  the  inflammatory  softening  of  the 
wall.  Clearly  the  abscess  had  its  origin  at  the  site  of  the  band,  and  the 
infection,  predisposed  to  by  the  gTeatly  enfeebled  condition  of  our  patient, 
had  its  immediate  cause  in  the  local  inoculation,  which,  in  turn,  was  to  be 
explained  by  the  fact  that  the  glove  had  to  be  removed  and  the  band  to  be 
rolled  by  the  bare,  although  carefully  disinfected,  fingers. 

This  case,  which  I  hope  to  publish  later  in  detail,  gives  us  great  encour- 
agement. Had  it  not  been  for  the  infection  the  aneurism  would,  we  think, 
probably  have  been  cured.  The  facts  that  the  aneurism  gradually  diminished 
in  size  until  on  the  fifth  day  it  was  hardly  demonstrable,  and  reappeared 
synchronously  with  the  manifestations  of  infection  justify  the  inference 
that  the  abscess  formation  was  responsible  for  the  result.  It  was  to  me  of 
particular  interest  to  note  that  the  aortic  wall  at  the  site  of  the  band  was 
intact  notwithstanding  the  infection  in  the  tissues  about  it. 

It  would  gratify  me  very  much  to  have  opportunities  to  test  again  the 
effect  of  partial  occlusion  of  the  abdominal  aorta  in  aneurism  of  the  vessel 
below  the  renal  arteries  and  in  aneurism  of  the  common  iliac  artery. 

The  partial  occlusion  of  arteries  by  the  metal  band  has,  I  think,  opened 
a  field  for  investigation  in  physiology  and  experimental  pathology  as  well 
as  in  surgery. 


THE  EFFECT  OF  LIGATION  OF  THE  COMMON  ILIAC  ARTERY 

OX  THE  CIRCULATION  AND  FUNCTION  OF 

THE  LOWER  EXTREMITY 

REPORT  OF  A  CURE  OF  ILIO-FEMORAL  ANEURISM  BY  THE 
APPLICATION  OF  AN  ALUMINUM  BAND  TO  THAT  VESSEL  1 

The  purpose  of  this  paper  is  not  so  much  to  publish  a  case  in  which  a 
cure  of  ilio-femoral  aneurism  was  accomplished  by  the  application  to  the 
common  iliac  artery  of  a  barely  or  completely  occluding  aluminum  band 
as  to  consider  the  reasons  for  the  view  which  prevails  that  ligation  of  this 
artery  is  an  exceedingly  dangerous  procedure  and  Likely  to  be  followed  by 
gangrene,  and  to  determine,  if  possible,  the  ultimate  result  of  this  opera- 
tion so  far  as  usefulness  of  the  Limb  is  concerned. 

I  have  endeavored  to  assemble  all  the  cases  of  ligation  of  the  common 
iliac  artery  reported  since  1880,  accepting,  in  order  to  avoid  confusion,  this 
arbitrary  date,  proposed  by  Dreist J  as  being  within  the  antiseptic  period. 
Although  antiseptic  surgery  was  not  universally  practised  until  after  1890 
in  the  United  States  and  Great  Britain,  the  countries  which  have  contributed 
most  to  the  surgery  of  the  common  iliac  and  of  the  other  large  arteries, 
infection  has  not  played  part  enough  in  the  cases  here  collected  to  obscure 
the  factors  responsible  for  the  results  and  thus  prevent  the  drawing  of 
deductions  concerning  the  matters  which  it  is  the  particular  purpose  of  this 
paper  to  consider. 

In  the  years  from  1880  to  1912,  the  common  iliac  artery  has  been  ligated 
at  least  30  tunes,  or  about  once  a  year,  for  the  control  of  haemorrhage  and 
the  cure  of  aneurism. 

Undoubtedly  the  reports  of  some  have  been  overlooked  by  me  and  the 
number  of  unpublished  cases  may  be  considerable.  The  Index  Medicus  has 
been  of  the  greatest  assistance  in  my  search,  not  one  of  the  cases  found  in 
other  medical  bibliographies  having  been  overlooked  by  this  indispensable 
work.  Only  three  of  the  published  cases  of  my  list  are  not  to  be  found  in 
the  admirably  arranged  and  marvellously  accurate  index  of  the  Index  Medi- 

1  Presented  at  the  American  Surgical  Association.  Montreal.  Canada,  May  29-31, 
1912. 
Johns  Hopkins  Hosp.  Bull.,  Bait.,  1912,  xxiii,  191-220.    (Reprinted.) 
Also:    Tr.  Am.  Surg.  Ass.,  Phila.,  1912,  xxs,  196-286. 
1  Deutsche  Ztschr.  f.  Chir,  1903,  bad,  Heft  1,  26. 


330  LIGATION  OF 

cus  and  there  is  good  excuse  for  the  omission  of  these,  there  being  no  titular 
indication  of  their  existence. 

Thanks  to  the  courtesy  of  Dr.  McCaw,  the  library  at  Washington  of  the 
Surgeon-General  has  been  at  my  disposition,  and  not  one  of  the  desired 
articles  has  been  wanting  from  its  shelves.  This  privilege  has  enabled  me 
to  make  an  abstract  from  the  original  article  in  every  case. 

The  common  iliac  artery  was  ligated  for  the  first  time  July  27,  1812,* 
just  one  hundred  years  ago,  and  in  this  period  it  has  been  tied  about  100 
times. 

The  original  operation  was  performed  for  the  arrest  of  haemorrhage  by 
William  Gibson/  at  that  time  Professor  of  Surgery  in  the  University  of 
Maryland,  Baltimore.  The  patient  was  a  male,  aet.  38.  A  musket  ball  enter- 
ing the  left  side  of  the  abdomen  passed  through  the  intestine,  opened  the 
left  common  iliac  artery  and  lodged  in  the  sacrum.  Peritonitis  developed 
promptly.  On  the  ninth  day  a  severe  haemorrhage  occurred.  From  this 
time,  until  the  death  of  the  patient,  on  the  fifteenth  day  after  operation, 
there  were  repeated  haemorrhages. 

Valentine  Mott  was  the  first  deliberately  to  tie  the  common  iliac  artery. 
The  operation,  undertaken  for  the  cure  of  ilio-femoral  aneurism,  was  suc- 
cessful. The  story  of  the  case  as  related  by  him  is  impressive  and  gives  one 
some  idea  of  the  courage,  skill,  sagacity  and  resourcefulness  of  this  remark- 
able man. 

The  following  passages  are  quoted  from  Dr.  Mott's  report : 5 

"  On  the  15th  of  March,  1827,  I  was  requested  to  visit  a  patient  with 
Dr.  Osborn  (of  Westfield,  New  Jersey,  about  twenty-five  miles  distant  from 
New  York)  whom  we  found  laboring  under  a  large  aneurism  of  the  right 
external  iliac  artery. 

"  Israel  Crane,  aged  33  years,  says  that  about  the  middle  of  January  he 
felt  some  pain  about  the  lower  part  of  the  belly,  which  he  attributed  to  a  fall 
received  during  the  winter. 

"  It,  however,  was  not  until  a  fortnight  since,  that  he  perceived  any  tumor 
about  the  lower  part  of  the  abdomen.  Upon  examination,  the  abdomen  on 
the  right  side  was  considerably  enlarged  from  about  the  crural  arch,  as  high 
as  the  umbilicus.  When  the  hand  was  applied  to  the  parietes  of  the  ab- 
domen a  pulsation  was  felt  and  rendered  visible  to  some  distance.  To  the 
touch,  the  tumor  beat  violently  and  appeared  to  contain  only  fluid  blood. 
It  commenced  a  little  above  Poupart's  ligament  and  reached,  judging  by 

3  Am.  M.  Recorder,  1820,  iii,  185. 

4  Dr.  Gibson  performed  this  operation  at  the  age  of  twenty-four.  It  was  due  to 
his  efforts  that,  the  previous  year,  the  Medical  School  in  which  he  held  the  Chair  of 
Surpery  was  founded. 

'Successful  Ligation  of  the  Common  Iliac  Artery.  By  Valentine  Mott,  M.  D., 
Professor  of  Surgery,  N.  Y.   Am.  J.  M.  Sc,  1827,  i,  156. 


COMMON  ILIAC  ARTERY  331 

the  touch,  from  without  near  the  navel — inwards,  almost  to  the  linea  alba — 
outwards  and  backwards  filling  up  all  the  concavity  of  the  ileum,  and  reach 
ing  beyond  the  posterior  superior  spinous  process  of  that  bone. 

"  The  rapid  increase  of  this  aneurismal  tumor  occasioned,  as  the  coun- 
tenance of  our  patient  indicated,  the  most  extreme  agony.  His  sufferings 
were  at  times  so  great  that  his  screams  could  be  heard  at  a  distance  from 
the  house.  He  had  been  bled  several  times,  taken  light  food,  and  was  kept 
constantly  under  the  influence  of  opium.  He  was  now  informed  of  the 
serious  nature  of  his  case,  and  that  without  an  operation  very  little  chance 
of  his  life  remained.  With  great  composure  he  immediately  consented  to 
whatever  would  give  him  the  best  prospect  of  saving  his  life. 

"  From  the  extent  and  situation  of  the  tumor,  he  was  apprised  of  the 
uncertain  nature  of  the  operation,  as  well  as  the  difficulty  of  performing  it, 
and  indeed  that  it  would  require  an  artery  to  be  tied,  which  never  had  been 
operated  upon  for  aneurism. 

"  With  these  views  of  his  situation,  he  cheerfully  submitted  to  be  placed 
upon  a  table  of  suitable  height  in  a  room  which  was  well  lighted. 

"  The  pubes  and  groin  of  the  right  side  being  shaved,  an  incision  was 
commenced  just  above  the  external  abdominal  ring,  and  carried  in  a  semi- 
circular direction  half  an  inch  above  Poupart's  ligament,  until  it  terminated 
a  little  beyond  the  anterior  superior  spinous  process  of  the  ilium,  making 
in  extent  about  five  inches. 

"  The  integuments  and  superficial  fascia  were  now  divided,  which  ex- 
posed the  tendinous  part  of  the  external  oblique  muscle,  upon  cutting  which 
in  the  whole  course  of  the  incision,  the  muscular  fibers  of  the  internal 
oblique  were  exposed;  the  fibers  of  which  were  cautiously  raised  with  the 
forceps  and  cut  from  the  upper  edge  of  Poupart's  ligament.  This  exposed 
the  spermatic  cord,  the  cellular  covering  of  which  was  now  raised  with  the 
forceps,  and  divided  to  an  extent  sufficient  to  admit  the  forefinger  of  the 
left  hand  to  pass  upon  the  cord  into  the  internal  abdominal  ring.  The  finger 
serving  now  as  a  director,  enabled  me  to  divide  the  internal  oblique  and 
transversalis  muscles  to  the  extent  of  the  external  incision,  while  it  pro- 
tected the  peritonaeum.  In  the  division  of  the  last  mentioned  muscles  out- 
wardly, the  circumflexa  ilii  artery  was  cut  through,  and  it  yielded  for  a  few 
minutes  a  smart  bleeding.  This,  with  a  smaller  artery  upon  the  surface  of 
the  internal  oblique  muscle,  between  the  rings,  and  one  in  the  integuments 
were  all  that  required  ligatures. 

"  With  the  tumor  beating  furiously  underneath,  I  now  attempted  to  raise 
the  peritonaeum  from  it.  which  we  found  difficult  and  dangerous,  as  it  was 
adherent  to  it  in  every  direction.  By  degrees  we  separated  it  with  great  cau- 
tion from  the  aneurismal  tumor,  which  now  bulged  up  very  much  into  the 
incision.  But  we  soon  found  that  the  external  incision  did  not  enable  us  to 
arrive  at  more  than  half  the  extent  of  the  tumor  upwards.  It  was,  there- 
fore, extended  upwards  and  backwards  about  half  an  inch  within  the  ilium, 
to  the  distance  of  three  inches,  making  a  wound  in  all  about  eight  inches 
in  length. 

"  The  separation  of  the  peritonaeum  was  now  continued,  until  the  fingers 
arrived  at  the  upper  part  of  the  tumor,  which  was  found  to  terminate  at  the 
going  off  of  the  internal  iliac  artery.   The  common  iliac  was  next  examined 


332  LIGATION  OF 

by  passing  the  fingers  upon  the  promontory  of  the  sacrum,  and  to  the  touch 
appearing  to  be  sound,  we  determined  to  place  our  ligature  upon  it  about 
half  way  between  the  aneurism  and  the  aorta,  with  a  view  to  allow  length  of 
vessel  enough  on  each  side  of  it  to  be  united  by  the  adhesive  process. 

"  The  great  current  of  blood  through  the  aorta  made  it  necessary  to  allow 
as  much  of  the  primitive  iliac  to  remain  between  it  and  the  ligature  as 
possible,  and  the  probable  disease  of  the  artery  higher  than  the  aneurism 
required  that  it  should  not  be  too  low  down.  The  depth  of  this  wound,  the 
size  of  the  aneurism,  and  the  pressure  of  the  intestines  downwards  by  the 
efforts  to  bear  pain,  made  it  almost  impossible  to  see  the  vessel  we  wished  to 
tie.  By  the  aid  of  curved  spatulas,  such  as  I  used  in  my  operation  upon 
the  innominata,  together  with  a  thin,  smooth  piece  of  board,  about  three 
inches  wide,  prepared  at  the  time,  we  succeeded  in  keeping  up  the  peritonaeal 
mass,  and  getting  a  distinct  view  of  the  arteria  iliaca  communis,  on  the 
side  of  the  sacro-vertebral  promontory.  This  required  great  effort  on  our 
part,  and  could  only  be  continued  for  a  few  seconds.  The  difficulty  was 
greatly  augmented  by  the  elevation  of  the  aneurismal  tumor,  and  the  inter- 
ception it  gave  to  the  admission  of  light. 

"  When  we  elevated  the  pelvis,  the  tumor  obstructed  our  sight ;  when  we 
depressed  it,  the  crowding  down  of  the  intestines  presented  another  difficulty. 

"  Introducing  my  right  hand  now  behind  the  peritonaeum,  the  artery  was 
denuded  with  the  nail  of  the  forefinger,  and  the  needle  conveying  the  liga- 
ture was  introduced  from  within  outwards,  guided  by  the  forefinger  of  the 
left  hand  in  order  to  avoid  injuring  the  vein.  The  ligature  was  very  readily 
passed  underneath  the  artery,  but  considerable  difficulty  was  experienced  in 
hooking  the  eye  of  the  needle,  from  the  great  depth  of  the  wound  and  the 
impossibility  of  seeing  it.  The  distance  of  the  artery  from  the  wound  was 
the  whole  length  of  my  aneurismal  needle. 

"  After  drawing  the  ligature  under  the  artery,  we  succeeded,  by  the  aid 
of  our  spatulas  and  board,  in  getting  a  fair  view  of  it,  and  were  satisfied 
that  it  was  fairly  under  the  primitive  iliac,  a  little  below  the  bifurcation 
of  the  aorta.  It  was  now  tied ;  the  knots  were  readily  conveyed  up  to  the 
artery  by  the  forefingers;  all  pulsation  in  the  tumor  instantly  ceased.  The 
ligature  upon  the  artery  was  very  little  below  a  point  opposite  the  umbilicus. 

"  The  operation  lasted  rather  less  than  one  hour. 

"  In  less  than  one  hour  from  the  operation,  considerable  reaction  of  the 
heart  and  arteries  took  place ;  he  felt,  as  he  stated,  altogether  relieved  from 
the  excruciating  agony  he  had  suffered  since  the  aneurism  commenced.  The 
whole  limb  had  now  recovered  its  natural  temperature. 

"March  16th. — The  day  after  the  operation;  pulse  eighty;  skin  moist; 
limb  warm  as  the  other ;  complains  of  some  pain  at  the  ligature ;  ordered  a 
purgative  of  neutral  salts. 

"March  11th  and  18th. — There  was  considerable  pain  in  the  limb. 

"April  8th. — There  are  no  disagreeable  appearances  whatever.  He  ap- 
pears to  be  doing  remarkably  well ;  has  been  bled  once  since  the  last  report ; 
takes  a  purgative  every  other  day,  and  an  opiate  every  night;  pulse  as  in 
health;  no  pain;  says  he  is  entirelv  comfortable;  wound  dressed  with  dry 
lint. 


COMMON  ILIAC  ARTERY  333 

"April  16th. — Has  improved  rapidly  since  the  last  report.  Two  days 
after  the  ligature  came  away  he  very  imprudently  got  out  of  bed  without 
experiencing  any  difficulty,  except  weakness.  Rode  out  today;  wound  per- 
fectly healed. 

"April  80th. — Is  perfectly  restored  to  health;  has  a  little  stoop  in  his 
walk,  which  he  says  is  occasioned  by  the  external  cicatrix.  Leg  is  not  yet 
of  its  full  size,  nor  quite  so  strong  as  the  other.  From  the  period  of  the 
operation,  to  the  recovery  of  our  patient,  he  did  not  appear  to  suffer  more 
pain,  or  to  have  more  unpleasant  symptoms,  than  would  ordinarily  take 
place  in  a  flesh  wound  of  equal  extent. 

"  May  29th. — My  patient  visited  me  today,  having  come  twenty-five  miles ; 
he  was  so  much  improved  in  health  that  I  did  not  recognize  him.  Examined 
the  cicatrix  and  found  it  perfectly  sound;  could  not  discover  any  remains 
of  aneurismal  tumor;  felt  the  epigastric  artery  much  enlarged  and  beating 
strongly  (italics  mine),  and  a  feeble,  though  distinct  pulsation  in  the 
femoral  artery  immediately  below  the  crural  arch.  The  leg  has  its  natural 
temperature  and  feeling,  and  he  says  it  is  as  strong  as  the  other. 

"  The  gratification  his  visit  afforded  me  is  not  to  be  imagined,  save  by 
those  who  have  been  placed  under  similar  circumstances.  The  perfect  suc- 
cess of  so  important  and  novel  an  operation,  with  the  entire  restoration  of 
the  patient's  health,  was  a  rich  reward  for  the  anxiety  I  experienced  in  the 
case,  and  in  a  measure  compensated  for  the  unexpected  failure  of  my  opera- 
tion on  the  arteria  innominata. 

*  Xew  York,  25  Park  Place,  October  15,  1827." 

It  is  interesting  to  note  that  Dr.  Mott  raised  the  pelvis,  just  as  we  do 
today,  with  the  object  of  having  the  abdominal  contents  gravitate  towards 
the  thorax.  Being  without  artificial  illumination  or  means  of  reflecting  the 
daylight  into  the  wound,  he  had  to  abandon  this  useful,  and  for  us  today, 
quite  indispensable  measure  because  with  the  pelvis  elevated,  the  aneuris- 
mal tumor  obstructed  the  view. 

In  1853,  Prof.  Uhde,  of  Braunschweig,  tabulated  17  cases  of  liga- 
tion of  the  common  iliac  artery  performed  to  the  year  1850  and  reported 
in  full  detail  a  case  in  which  he  tied  this  vessel  for  aneurism  of  the  gluteal 
artery.  The  article  is  illustrated  with  interesting  wood-cuts  depicting  the 
conditions  found  by  him  at  the  autopsy  of  his  patient.  Uhde  tabulated  also, 
in  this  paper,  the  ligations,  to  1852,  of  various  arteries  for  the  cure  of  glu- 
teal aneurism. 

Of  the  statistical  papers  on  the  subject  of  ligation  of  the  common  iliac 
artery  the  classic  one  of  Stephen  Smith,8  published  in  1860,  is  especially 
important. 

6  A  Statistical  Examination  of  the  Operation  of  Deligation  of  the  Primitive  Iliac 
Artery,  embracing  the  Histories  (in  abstract)  of  Thirty-Two  Cases,  By  Stephen 
Smith,  M.  D.,  Surgeon  to  Bellevue  Hospital,  Xew  York.  Am.  J.  M.  Sc,  1860, 
n.  s.  xl.  18 


331 


LIGATION  OF 


It  is  a  tale  of  woe  that  Dr.  Smith  had  to  relate,  tragic  for  the  patient 
and  for  the  surgeon ;  but  hardly  more  pitiful  than  is  to  be  found  in  the  his- 
tory of  the  operation  as  it  has  been  performed  in  our  modern  antiseptic 
and  aseptic  times. 

Stephen  Smith  collected  31  cases  of  ligation  of  the  common  iliac  artery 
and  reported  an  additional  case  of  his  own.  In  the  32  years  from  1829  to 
1859,  32  T  ligations  of  this  artery  were  made  and  this  average  of  one  a  year 
has  been  approximately  maintained  to  the  present  time. 

In  the  following  table  Dr.  Smith  has  arranged  the  cases  in  chronological 
order  {I.  c,  p.  19). 


Ha 

Date  of  operatii 

m 

Operator 

Result 

1 

July 

27. 

1812 

Gibson,  of  Philadelphia 

Died 

2 

March 

15. 

1827 

Mott,  of  New  York 

Cured 

3 

July 

18, 

1828 

Crampton,  of  Dublin 

Died 

4 

December 

1. 

1829 

Liston,  of  Edinburg 

Died 

5 

August 

24. 

1S33 

Guthrie,  of  London 

Cured 

6 

April 

1836 

Stevens,  of  New  York 

Died 

7 

May 

26. 

1837 

Salomon,  of  St.  Petersburg 

Cured 

8 

1837 

Garviso,  of  Monte  Video 

Died 

9 

June 

8, 

1838 

Syme,  of  Edinburgh 

Died 

10 

November 

29, 

1838 

Pirogoff ,  of  Dorpat 

Died 

11 

April 

10. 

1S39 

Bushe.  of  New  York 

Died 

12 

February 

22. 

1840 

Deguise,  of  Paris 

Cured 

13 

August 

26, 

1S40 

Post,  of  New  York 

Died 

14 

August 

29, 

1842 

Peace,  of  Philadelphia 

Cured 

15 

December 

3, 

1S43 

Hey.  of  New  York 

Cured 

US 

1S43 

Garviso,  of  Monte  Video 

Cured 

17 

January 

27. 

1S45 

Stanley-,  of  London 

Died 

IS 

June 

3. 

1S47 

Lyon,  of  Glasgow 

Died 

u 

September 

19, 

1850 

Chassaignac,  of  Paris 

Died 

20 

December 

29. 

1851 

Jones,  of  Liverpool 

Died 

21 

January 

1852 

Moore,  of  London 

Died 

22 

March 

27. 

1852 

Wedderburn.  of  New  Orleans 

Died 

23 

October 

7. 

1S52 

Uhde.  of  Braunschweig 

Died 

24 

November 

1S53 

Van  Buren,  of  New  York 

Died 

25 

March 

20. 

1857 

Edwards,  of  Edinburgh 

Died 

26 

March 

26. 

1857 

Holt,  of  Georgia 

Died 

27 

July 

15. 

1857 

Meier,  of  New  York 

Died 

-'v 

July 

3. 

185S 

Parker,  of  New  York 

Died 

28 

July 

6. 

1858 

Buck,  of  New  York 

Died 

30 

October 

6. 

1858 

Stephen  Smith,  of  New  York 

Died 

31 

January 

26. 

1859 

Stone,  of  New  Orleans 

Died 

32 

Goldsmith,  Louisville 

Died 

T  The  date  of  the  32d  operation  by  Middleton  Goldsmith  was  not  obtainable,  but 
as  Prof.  Goldsmith  reported  it  in  February.  I860  (Louisville  Medical  Journal),  the 
operation  was  presumably  performed  in  1859.  or  earlier. 


COMMON  ILIAC  AETEEY  335 

"  The  indications,"  Dr.  Smith  writes.  "  which  have  thus  far  led  to  the 
deligation  of  the  primitive  iliac  artery  may  be  divided  as  follows : 

"  I.  For  the  arrest  of  haemorrhage. 

"  II.  For  the  cure  of  aneurism. 

"  III.  For  the  cure  of  pulsating  tumors,  which  proved  to  be  malignant 
growths. 

"  IV.  For  the  prevention  of  haemorrhage  in  the  removal  of  a  morbid 

gTOWth." 

In  Group  I  are  eleven  cases.  Ten  of  these  died ;  nine  from  haemorrhage, 
primary  (five),  or  secondary  (four)  :  one  from  peritonitis.  Dr.  Smith  con- 
trasts the  mortality  from  ligation  of  the  primitive  iliac  artery  for  the  arrest 
of  haemorrhage  (approximately  91  per  cent)  with  that  following  the  same 
operation  performed  14  times  upon  the  external  iliac  artery  for  the  same 
causes  (2H  per  cent)  and  makes  this  comment  "a  proper  appreciation  of 
the  circumstances  under  which  the  primitive  iliac  artery  has  been  tied  for 
the  arrest  of  haemorrhage  will  lead  the  discriminating  surgeon,  notwith- 
standing the  excessive  mortality  that  has  thus  far  attended  its  performance, 
to  accord  to  this  operation  an  important  place  among  the  resources  of 
his  art." 

In  Group  II  (for  the  cure  of  aneurism)  there  are  15  cases.  Five  of  these 
recovered:  ten  died;  in  two  the  result  was  unknown.  This  group  has  the 
greatest  percentage  of  recovery  from  the  operation  and  it  is  noteworthy  that 
in  at  least  one,  Peace's,  of  the  non-fatal  cases,  ligation  of  the  common  iliac 
artery  did  not  suffice  to  cure  permanently  the  aneurism  which  returned  about 
14  months  later,  ruptured  and  caused  the  death  of  the  patient.  In  one  of 
the  recovered  cases,  Salomon's,  gangrene  ensued  as  result  of  the  ligation. 
In  this  instance,  a  gangrenous  eschar  formed  on  the  foot  on  the  third  day 
after  operation,  and  "  subsequently  others  appeared,"  but  "  convalescence 
was  complete  at  the  end  of  two  months."  This  patient  died  ten  months  after 
the  operation  from  an  abscess  below  Poupart's  ligament  on  the  operated  side. 

Gangrene  was  the  cause  of  death  in  two  of  the  fatal  cases,  but  in  one  of 
these,  Syme's,  it  was  present  before  operation. 

Dr.  Smith  makes  the  following  comment  in  considering  the  results  of  the 
operation  of  deligation  of  the  common  iliac  artery  for  aneurism,  as  com- 
pared with  the  same  operation  upon  the  external  iliac : 

"  In  ninety-five  cases,  which  I  have  examined,  of  ligation  of  the  latter 
(external  iliac)  artery  for  aneurism,  sixty-nine  recovered  and  twenty-six 
died,  being  a  mortality  of  about  27  per  cent,  or  less  than  half  the  mortality 
of  the  same  operation  for  the  same  disease  when  performed  upon  the  com- 
mon trunk.  The  cause  of  death  in  eleven  cases,  or  nearly  one  half,  of 
ligation  of  the  external  iliac  for  aneurism  was  mortification  of  the  limb, 


336  LIGATION  OF 

presenting  a  striking  contrast  with  the  same  operation  upon  the  primitive 
iliac  in  which  there  was  but  one  instance  in  eight  cases." 

Group  III.  Deligation  of  the  common  iliac  for  malignant  tumors  simu- 
lating aneurism.  It  is  noteworthy  that  in  all  four  of  the  cases  in  this  group 
the  pulsating  neoplasm  was  mistaken  for  aneurism.  Mr.  Astley  Cooper  who 
saw.  in  consultation,  Mr.  Guthrie's  case  expressed  himself  as  positive  that 
it  was  an  aneurism. 

In  Group  IV  are  two  unclassified  cases.  The  second  of  these,  Chassaig- 
nac's,  was,  as  Dr.  Smith  says,  one  of  the  most  remarkable  of  the  series.  This 
eminent  surgeon  operated  in  a  most  brilliant  manner  for  the  cure  of  a  large 
encephaloid  tumor  of  the  internal  and  superior  aspect  of  the  thigh,  extend- 
ing to  the  foramen  ovale,  and  after  ligation  of  the  common  iliac  artery,  the 
tumor  was  removed,  "with  scarcely  the  appearance  of  blood."  The  entire 
operation,  performed  under  chloroform,  lasted  only  half  an  hour. 

Surgeons  of  the  present  day  would  be  entertained  by  the  perusal  of  the 
comments  which  Chassaignac's  report  of  the  case  called  forth,  at  a  meeting 
of  the  Societe  de  Chirurgie.*  Dr.  Smith  gives  an  abstract  of  the  discussion. 
Larrey,  Eobert  and  Forget  condemned  the  operation  in  unqualified  terms, 
Larrey  blaming  the  operator  for  attempting  so  considerable  an  operation 
without  previous  consultation  with  his  colleagues.  Gosselin  and  Maison- 
neuve  sustained  Chassaignac. 

In  the  32  cases  the  extraperitonaeal  incision  was  employed  by  all  the 
operators  with  the  exception  of  Gibson,  Garviso,  Post  and  Goldsmith.  Of 
the  nine  cases  in  which  the  peritonaeal  cavity  was  opened,  either  accidentally 
or  intentionally,  only  two  acquired  peritonitis,  and  in  both  of  these  haemor- 
rhage was  an  associated  cause  of  death. 

Another  paper  of  importance  on  the  subject  of  ligation  of  the  common 
iliac  artery  and  almost  equal  in  statistical  value  to  Stephen  Smith's,  is  by 
Kummel,'  assistant  at  that  time  (1884)  of  Prof.  Schede  in  the  Allege- 
meines  Krankenhaus  zu  Hamburg,  and  at  present  Surgical  Director  of  the 
Eppendorf  Hospital,  Hamburg,  which  is  so  well  known  to  surgeons  through- 
out the  world.  To  the  32  cases  of  Stephen  Smith,  Kiimmel  adds  30,  col- 
lected from  the  24  years  between  1860  and  1884,  an  average  of  one-quarter 
of  a  case  per  year  in  excess  of  the  record  of  the  first  32  years  in  the  history 
of  the  ligation  of  this  artery. 

With  one  or  two  exceptions,  the  complications  which  have  led  to  the  per- 
formance of  this  operation  have  been  of  grave  import.  In  Groups  III "  and 

•Bull.  Soc.  de  chir.  de  Par.    Paris,  1851. 
*  Kiimmel.  Arch.  f.  klin.  Chir.,  1884.  xxx.  65. 

"Group  III.  Ligations  of  the  common  iliac  for  the  cure  of  pulsating,  malignant 
growths. 


COMMON  ILIAC  AETEBY  337 

IV  u  of  Stephen  Smith  they  are  obviously  of  such  nature  as  to  make  the 
cases  comprised  in  these  groups  useless  for  the  purpose  of  this  study. 

We  shall  consider,  therefore,  only  cases  which  have  been  operated  upon 
for  the  control  of  haemorrhage  (Group  I),  or  the  cure  of  aneurism 
(Group  II). 

ABSTRACTS  OF  CASES  FROM  18S0  TO  1912 

1.  (Group  I.)  O'Grady.  E.  S.  Ligation  of  the  left  common  and  internal 
iliac  arteries  to  arrest  haemorrhage  in  a  case  of  varicose  aneurism  for  the 
cure  of  which  the  femoral  artery  had  been  ligated  nine  months  previously. 
Death  in  about  seven  hours.  (The  Medical  Eress  and  Circular.  Dublin, 
1880,  July  28th,  p.  71.) 

Male,  aet.  28.  At  the  age  of  13,  patient  clapped  his  thighs  together  to 
catch  a  shoemaker's  knife.  The  sharp  knife  "  transfixed  the  long  saphenous 
vein  and  penetrated  the  femoral  artery."  Since  the  accident  he  had  required 
surgical  assistance  at  various  times.  With  the  aid  of  rest  and  the  habitual 
use  of  an  elastic  bandage  he  had  managed  to  earn  a  living.  A  pulsating 
tumor  had  formed  "  in  the  anterior  and  inner  region  of  the  middle  of  the 
left  thigh."  When  examined  by  Mr.  O'Grady  (presumably  in  Xovember, 
1879),  this  tumor  was  as  large  as  a  cocoanut,  and  very  prominent.  From 
its  lower  part,  there  projected  two  hemispherical  nodules  as  large  as  walnuts. 
The  tissue  intervening  between  these  and  the  pulsating  finger  was  so  thin 
that  it  seemed  as  if  the  pulsating  tumor  might  burst  at  any  moment. 
Eressure  on  the  femoral  artery  above  stopped  the  pulsation.  The  long 
saphenous  vein,  dilated  to  the  size  of  a  man's  thumb,  u  traversed  and  was 
imbedded  in  the  mass."  "  There  were  enormously  large  knots  of  dilated  and 
tortuous  veins  behind  the  knee  and  down  the  leg."  A  bruit  was  distinctly 
audible  to  bystanders  and  could  be  loudly  heard  over  the  heart. 

Operation. —  (Xovember  ?,  1879.)  Two  days  after  admission  to  the 
Mercer's  Hospital,  Dublin,  the  superficial  femoral,  cut  down  upon,  was 
found  to  be  as  large  as  "  a  large  man's  middle  finger  " ;  its  coats  were  "  thin 
and  unhealthy  looking."  The  vessel  was  ligated  with  carbolized  catgut  in 
two  places  and  cut  between,  the  upper  ligature  being  about  one  inch  below 
the  origin  of  the  profunda  artery.  Each  of  the  divided  ends  was  again  tied 
with  a  ligature  of  the  same  material.  The  wound  was  loosely  closed  with  two 
interrupted  sutures  and  covered  with  lint  moistened  in  carbolized  oil.  The 
limb  was  wrapped  in  flannel  bandages  and  surrounded  by  hot  jars.  Three 
hours  after  the  operation  the  foot  and  leg  were  found  to  be  very  cold. 
The  following  morning  they  became  warmer.  The  tumor  was  quite  solid. 
Three  days  later  the  wound  and  parts  about  it  were  considerably  inflamed, 
but  there'  was  no  return  of  the  pulsation  or  thrill.  The  latter  lessened  in 
intensity,  "  soon "  returned,  however,  in  the  long  saphenous  vein  which 
"  stood  out  large  and  distended."  Attempts,  continued  for  some  weeks,  to 
bring  about  obliteration  of  this  vein  by  pressure  with  padded  corks  proved 
ineffectual. 

n  Group  IV.  For  the  prevention  of  haemorrhage  in  the  removal  of  a  morbid  growth. 


338  LIGATION  OF 

"  Sixty-six  days  after  the  deligation  an  aqueous  solution  of  perchloride 
of  iron  was  injected  into  a  carefully  insulated  portion  of  the  saphenous 
vein,  the  region  selected  being  the  central  two  inches  where  it  crossed  the 
tumor."  Ten  days  later  the  same  procedure  was  repeated  without  the  desired 
result.  But  a  week  later  a  like  injection,  made  lower  down  into  the  vein, 
was  followed  by  a  satisfactory  local  reaction,  which  in  two  days  had  sprung 
up  and  down  the  vein  and  "  thoroughly  coagulated  its  contents  for  its  entire 
length." 

One  hundred  and  forty-eight  days  after  the  operation  the  patient  left 
the  hospital,  his  departure  having  been  delayed  by  "  recurrent  attacks  of 
more  or  less  severe  inflammation  of  the  glands  of  the  groin."  The  vein 
remained  obliterated,  and  the  aneurism  was  slowly  getting  smaller.  July  5th, 
nine  months  after  the  deligation  of  the  femoral  artery,  the  patient  returned 
to  the  hospital  because  there  had  been  slight  bleeding  from  the  cicatrix. 
He  reported  that  there  had  been  occasional  attacks  of  inflammation  in  the 
groin,  and  that  from  a  particular  spot  in  the  cicatrix  there  would  be  dis- 
charged, every  now  and  then,  a  drop  or  two  of  thin  matter. 

Examination. — The  right  groin  and  the  abdomen  to  the  ribs  were  swollen 
and  tender  and  reddened  with  an  erysipelatous  blush.  There  was  pulsation 
in  "  the  stump  of  the  femoral,"  but  the  swollen  condition  of  the  parts  pre- 
cluded the  possibility  of  recognizing  with  certainty  "  how  far  any  fresh 
aneurism  formation  might  be  present." 

"  On  the  night  of  the  8th,  it  could  be  determined  that  an  aneurism  had 
formed  on  the  stump  of  the  femoral,  and  was  rapidly  increasing  in  size." 

July  9th. — At  7.45  a.  m.,  "  a  terrible  gush  of  arterial  haemorrhage  oc- 
curred," which,  "  though  arrested  '  on  the  moment/  left  the  patient  blanched 
and  prostrate." 

Two  hours  later,  the  patient  having  rallied  a  little,  the  external  iliac 
artery  was  cut  down  upon  through  matted  tissues  and  adherent  glands,  but 
the  vessel,  found  to  be  enormously  enlarged,  could  not  be  isolated.  So  the 
incision  was  prolonged  to  the  tip  of  the  twelfth  rib.  The  external  iliac 
artery  was  followed  up.  It  was  tortuous  and  "  as  big  as  a  sausage,"  "  re- 
sembling a  coil  of  intestine."  The  internal  iliac,  "  atrophied  rather  than 
enlarged,"  was  ligated  with  catgut  and  the  common  iliac  artery  as  well. 

The  patient  rallied  and  complained  of  great  pain  along  the  front  of  the 
tibia. 

Seven  hours  later,  becoming  suddenly  pulseless,  he  died. 

Under  difficult  conditions  a  local  examination  was  effected.  There  had 
been  no  further  bleeding,  and  nothing  was  found  to  account  for  the  sudden 
demise.  "The  external  iliac  much  exceeded  the  abdominal  aorta  in  size; 
it  was  a  marvel  how  such  a  river  of  blood  was  controlled  promptly  enough 
to  prevent  immediate  death."  The  long  saphenous  vein  was  atrophied  and 
impervious. 

2.  (Group  II.)  Richter,  C.  M.  Ligation  of  the  right  common  iliac  for 
huge  aneurism  of  the  external  iliac  artery.  Gangrene  before  operation. 
(Max  Richter,  Pacific  Medical  and  Surgical  Journal,  1880-1881,  p.  505.) 

Male,  act.  30.  Admitted  to  the  German  Hospital,  San  Francisco  ( ?), 
January  (?),  1881.  "Rheumatic"  pain  in  right  inguinal  region  six  and 
one-half  months  before  admission. 


COMMON  ILIAC  ARTERY  339 

Examination. — An  irregular  tumor  the  size  of  a  child's  head  occupied 
the  right  hypogastrium.  Pulsation  not  discernible.  On  auscultation  a  re- 
mote bruit  could  be  heard.  Arterial  blood  was  aspirated  with  a  hypodermic 
syringe.  The  right  leg  was  oedematous,  and  its  circumference  about  twice 
that  of  the  other.  Sensibility  normal.  Motility  unimpaired.  Patient  was 
very  anaemic,  suffered  from  dyspepsia  and  constipation  and  from  severe  pains 
in  the  right  leg  and  sacral  region,  which  recurred  every  morning.  The 
proposition  to  ligate  the  common  iliac  was  not  acceded  to  by  the  patient  for 
several  weeks.  The  tumor  meanwhile  increased  in  size,  the  pains  became 
more  severe,  and  finally  intolerable  and  uncontrollable  by  morphia.  Power 
of  motion  in  the  leg  became  lost  and  signs  of  gangrene  appeared.  Finally 
the  patient  consented  to  the  operation. 

February  19th. — The  right  common  iliac  was  ligated  by  Dr.  C.  M.  Richter. 
On  account  of  the  enormous  size  of  the  aneurism  and  the  oedema  in  the 
tissues  about  it,  the  incision  was  made  on  the  left  side,  parallel  to  Poupart's 
ligament,  and  the  artery  exposed  extraperitonaeally.  The  artery  was  tied 
with  a  silk  ligature  about  one-half  inch  from  its  origin.  The  aneurism  col- 
lapsed, but  the  gangrene,  in  two  days,  had  extended  to  the  knee.  The  limb 
was  anaesthetic  as  high  as  Poupart's  ligament.  Nowhere  in  the  extremity 
could  arterial  pulsation  be  felt.  Three  days  after  ligation,  amputation  of 
the  thigh  was  made.  The  operation  was  performed  according  to  the  anti- 
septic method  of  Lister.  An  Esmarch  bandage  was  applied  just  below 
Poupart's  ligament,  and  the  amputation  performed  in  a  manner  quite 
bloodless.  The  large  arteries  were  filled  with  recently  coagulated  blood.  On 
removal  of  the  Esmarch  bandage,  vessels  bled  from  all  parts  of  the  stump, 
and  twenty  or  thirty  blood  vessels  were  ligated. 

On  the  ninth  day  the  surface  of  the  stump  appeared  to  be  gangrenous. 
Chloride  of  zinc  was  applied,  seemingly  with  good  effect.  On  the  thirteenth 
day  afterwards,  there  was  a  rise  in  temperature,  but  the  wound  was  granu- 
lating satisfactorily.  Pus  was  discharged  from  the  abdominal  wound  on  the 
fifteenth  day. 

On  the  thirty-third  day  after  operation,  the  patient  was  doing  well.  The 
ligature  had  not  yet  come  away,  but  ultimate  recovery  seemed  assured. 

3.  (Group  II.)  Xicoladoni.  Ligature  of  the  right  common  iliac  artery 
for  spurious  aneurism  of  the  right  hypogastric  region.  Death  forty-five 
hours  after  operation.  (August  Sulzenbacher.  Wiener  medicinische  Presse, 
1882,  Nos.  7,  8,  and  9.) 

Male,  aet.  31.  Admitted  to  the  Innsbruck  Hospital,  November  11,  1881. 
Four  weeks  before  admission  was  wounded  in  the  right  groin  with  a  knife. 
Profuse  bleeding  from  the  wound  was  controlled  by  pressure  of  the  patient's 
hand  until  his  strength  failed ;  then,  with  both  hands,  he  pressed  the  flexed 
thigh  on  the  body  in  order  to  arrest  the  haemorrhage.  In  this  position  the 
patient  was  carried  to  the  Bozener  Stadtshospital.  On  arrival,  the  bleeding 
had  ceased.  A  wound  in  the  middle  of  the  right  inguinal  fold,  promptly 
closed  with  stitches,  healed  with  the  formation  of  a  small  abscess.  Thirteen 
days  later,  apparently  recovered,  he  left  the  hospital,  but  soon  applied  for 
admission,  because  a  tumor  had  developed  in  the  right  hypogastrium,  which 
from  day  to  day  increased  in  size. 


340  LIGATION  OF 

Examination  (on  admission  to  Professor  Nicoladoni's  clinic). — Skin  and 
mucous  membrane  pale,  voice  weak  and  motions  strengthless.  The  right 
lower  extremity,  swollen,  bent  at  knee,  and  hip  rotated  outwards.  The  swell- 
ing was  greatest  at  junction  of  thigh  and  trunk,  where  the  skin  was  tense 
and  glistening,  and  the  ramifications  of  the  veins  dilated.  A  pulse  in  the 
femoral  artery  could  be  felt,  but  it  was  barely  perceptible  in  the  posterior 
tibial.  The  entire  right  hypogastrium  was  conspicuously  vaulted  by  a  hard, 
and,  in  places,  nodular  tumor  which  extended  from  the  anterior  superior 
spine  to  beyond  the  middle  line,  and  from  two  inches  below  the  navel  into 
the  pelvis  behind  the  symphysis.  On  palpation,  a  peculiar  vibrating  thrill 
and  slight  heaving  synchronous  with  the  heart's  systole  could  be  appreciated. 
From  the  rectum  a  hard  tumefaction  was  felt  on  the  right  side. 

Diagnosis. — "  Aneurysma  Spurium ;  masses  of  coagulated  blood  in  the 
pelvis;  wound  of  epigastric  artery,  probable;  of  external  iliac  artery,  or  of 
both  these  vessels,  possible."  It  was  emphasized  that  the  femoral  artery 
pulsated  peripherally  to  the  seat  of  the  injury. 

Operation. — Nicoladoni.  November  15,  1881.  Long,  mid-line  incision  to 
give  ready  access  to  the  large  arteries  in  case  of  necessity.  Then  a  long 
incision  parallel  to  Poupart's  and,  finally,  through  this  ligament  in  search 
for  the  epigastric  artery,  and  to  expose  the  femoral  vessels. 

On  the  accidental  opening  of  the  sac,  a  profuse  spurting  haemorrhage 
occurred.  After  a  vain  attempt  to  isolate  the  pulsating  external  iliac  from 
the  wall  of  the  aneurism,  the  peritonaeal  cavity  was  entered  and  the  common 
iliac  artery  ligated  with  iodoformized  silk.  Thus  the  pulsation  and  bleeding 
were  completely  arrested.  Intestines  which  had  been  eventrated  to  facilitate 
the  operation  were  replaced  and  the  abdominal  wound  sutured.  Then  the 
femoral  artery  was  ligated  peripherally,  and  the  aneurismal  sac  laid  open. 
In  a  small  cavity,  the  size  of  a  hen's  egg,  a  hole  in  the  upper  side  of  the 
femoral  (?)  artery  was  found;  a  second  larger  cavity  led  into  a  wide  sub- 
peritonaeal  space.  Arterial  haemorrhage  "  from  the  peripheral  end  of  the 
external  iliac"  (?)  was  controlled  by  the  central  ligation  of  this  vessel. 
Great  masses  of  blood  coagula,  black  and  rusty  brown  in  color,  were  removed 
from  the  spurious  sac,  which  extending  into  the  small  pelvis  and  filling  the 
iliac  fossa,  had  dissected  down  the  thigh  under  the  fascia  lata  and  between 
the  muscles.  Wound  closed,  drained  and  covered  with  antiseptic  dressing. 
Duration  of  operation,  with  deep  narcosis,  three  and  one-half  hours. 

The  following  day,  November  16th,  pain  in  leg  and,  later,  in  abdomen. 
Great  thirst  and  restlessness.   Pulse  144,  temperature  102. 

November  17th. — Death  at  10  a.  m.,  forty-five  hours  after  operation. 

Autopsy. — Ligature  on  common  iliac,  2.5  cm.  below  aortic  division.  Above 
this  point,  a  soft  clot  in  the  artery.  Eight  internal  iliac  artery  decidedly 
larger  than  the  left.  The  crural  artery  together  with  the  epigastric  ligated 
at  Poupart's  ligament.  In  the  anterior  abdominal  wall,  the  epigastric  artery 
had  been  cut  through  not  far  from  its  origin.  The  femoral  vein  was  dilated 
and  filled  with  a  tough  and  adherent  thrombus,  on  removal  of  which  there 
was  found  in  the  posterior  wall  of  the  vessel  a  sharp-edged  slit.  The  femoral 
artery,  united  with  dense  connective  tissue  to  the  vein,  was  found  to  be  again 
ligated  below  Poupart's  ligament.  The  stabbing  knife  had,  therefore,  cut 
across  the  epigastric  artery  near  its  origin  and  into  the  femoral  artery  and 


COMMON  ILIAC  ARTERY  341 

vein,  thus  confirming  one  of  the  possibilities  formulated  in  making  the 
diagnosis.  No  reference  is  made  to  the  condition  of  the  circulation  in  the 
foot. 

4.  (Group  II.)  Lange,  F.  Ligation  of  the  left  common  iliac  artery  for 
ileo-femoral  aneurism.  Cutaneous  gangrene  of  great  toe.  Cure  of  aneurism. 
(New  York  Medical  Journal,  1883,  p.  610.) 

Patient,  male,  aet.  36.  Denied  syphilis,  but  had  had  leutic  manifestations. 
In  July,  1882,  the  patient  experienced  pain  about  the  left  knee,  which  ap- 
peared quite  suddenly  and  caused  pronounced  lameness  for  a  time.  He 
noticed  also  a  lump  about  the  size  of  a  pigeon's  egg  in  the  left  groin.  Never 
entirely  free  from  soreness  in  the  knee  joint,  he  suffered  at  times  intensely 
until  January,  1883.  The  patient  was  seen  by  Dr.  Lange  for  the  first  time 
in  July,  1883.  At  that  time,  "  a  pulsating  tumor  with  all  the  characteristics 
of  an  aneurism  occupied  almost  the  whole  of  the  left  iliac  fossa,  causing  the 
abdominal  wall  to  protrude  above  Poupart's  ligament.  Its  upper  boundary 
ran  from  the  anterior  spinous  process  toward  the  umbilicus,  ending  about 
an  inch  below  the  latter  in  the  middle  line  which  formed  its  mesial  outline. 
A  spindle-shaped  process  of  the  tumor  extended  in  the  direction  of  the 
femoral  artery  below  Poupart's  ligament.  But  nowhere  could  arterial  pul- 
sation be  detected  in  the  limb,  which  was  cool  and  had  a  bluish  hue." 

Operation,  July  26th. — Intraperitoneal  ligation  of  the  common  iliac 
artery.  Silk,  ligature,  ends  cut  short.  "  No  bad  symptoms  followed  the  opera- 
tion, and  the  vitality  of  the  limb  remained  unimpaired,  excepting  a  small 
cutaneous  necrosis  of  the  great  toe." 

Three  months  later  the  temperature  of  the  affected  limb  had  become  more 
nearly  normal,  but  it  was  paler  in  color  than  the  other,  and  was  less  well 
nourished.  Its  sensibility  was  normal,  but  its  reflex  irritability  was  dimin- 
ished. The  pain  had  ceased  and  the  tumor  had  shrunk  to  the  size  of  an 
orange.  The  coolness,  numbness  and  blueness  of  the  leg  before  operation 
presaged  insufficient  collateral  circulation. 

5.  (Group  I.)  Kummel,  H.  Ligation  of  the  left  common  iliac,  of  the 
external  iliac  (twice),  of  the  femoral  {three  times),  and  probably  of  the 
epigastric  and  circumflex  iliac  arteries,  without  gangrene.  After,  however, 
the  ligation  of  three  similar  arteries  (presumably  profunda,  internal  circum- 
flex and  external  circumflex) ,  gangrene  supervened.  Recovery.  (Verhand. 
d.  Deutsch.  Gesellsch.  f.  Chir.,  1883,  and  Archiv  f.  klin.  Chirurgie,  1884, 
xxx,  67.) 

Male,  aet.  21.  Following  operation,  by  an  unnamed  surgeon,  for  bubo 
inguinalis  on  both  sides,  there  occurred  a  diphtheritic  inflammation  of  the 
wound  of  the  left  groin. 

November  26,  188S. — (  ?),  four  days  after  the  operation,  a  profuse  haem- 
orrhage took  place  from  the  eroded  left  femoral  artery.  The  bleeding  was 
arrested  promptly  by  digital  compression  and  artery  clamps.  Dr.  Schede 
placed  two  ligatures  of  silk  on  the  femoral  artery  immediately  under  Pou- 
part's ligament,  and  divided  the  vessel  between  them.  He  also  "  tied  off 
certain  vessels  opening  into  the  artery  above  the  ligatures."  (Epigastric 
and  circumflex  iliac  ?).  It  was  found  that  perforation  of  the  femoral  artery 
had  occurred  in  two  places.   The  circulation  of  the  leg  was  completely  re- 


342  LIGATION  OF 

stored  by  evening  of  the  day  of  operation.  The  energetic  use  of  concen- 
trated solutions  of  corrosive  sublimate  arrested  the  diphtheritic  process  in 
the  wound,  but  caused  salivation  and  bloody  stools.  The  symptoms  of  mer- 
curial poisoning  subsided  in  a  few  days  under  appropriate  treatment. 

November  30th. — Severe  haemorrhage  from  the  central  end  of  the  femoral 
artery.  Although  the  bleeding  was  promptly  checked  with  digital  compres- 
sion by  an  orderly,  and  then  by  artery  clamps  applied  by  Dr.  Kumniel,  the 
loss  of  blood  was  badly  tolerated  by  the  already  greatly  reduced  patient. 

Having  transported  the  patient  to  the  operating  room,  Dr.  Kiimmel 
ligated  with  catgut,  extraperitonaeally,  the  external  iliac  artery,  believing  it 
wiser  to  operate  at  some  distance  from  the  infected  wound,  and  having 
found  it  impossible  to  make  the  ligation  in  loco.  On  removing  the  artery 
forceps,  which  had  been  applied  to  check  the  haemorrhage  from  the  femoral 
artery,  there  spurted  forth  a  stream  as  powerful  as  before.  Attempts  to 
ligate  the  femoral  (central  end)  proving  again  futile,  the  external  iliac 
was  tied  once  more,  just  below  its  origin  from  the  primitive  iliac,  but  with- 
out the  least  influence  upon  the  bleeding.  Hence  the  common  iliac  was 
ligated  (with  catgut,  extraperitonaeally)  about  3  cm.  above  its  bifurcation. 
Thereupon  the  bleeding  ceased  completely.  Throughout  the  operation  the 
wound  was  almost  continuously  irrigated  with  a  solution  of  bichloride  of 
mercury  (1-1000),  and  occasionally  flushed  with  basins  full  of  the  same 
solution.  Several  thick,  glass  u  drains  were  carried  down  to  the  site  of  the 
ligature  on  the  common  iliac;  the  wound  was  stitched  and  dressed  with 
glass-wool  and  sublimate  gauze. 

The  patient  was  in  the  highest  degree  exhausted  by  the  operation.  Pulse 
120  and  thread-like.  The  left  lower  extremity  quite  cold.  On  the  following 
morning,  however,  the  circulation  of  the  limb  was  completely  restored.  Thus 
ligation  of  the  common  iliac  after  double  ligation  of  the  femoral,  double 
ligation  of  the  external  iliac,  and  ligation,  supposedly,  of  the  circumflex 
iliac  and  epigastric  vessels  had  not  apparently  impaired  the  circulation  of 
the  limb,  notwithstanding  the  greatly  exsanguinated  and  exhausted  condi- 
tion of  the  patient. 

Needle  pricks  were  well  perceived  and  accurately  located.  Motility  was 
unimpaired.  Severe  pains  in  the  limb  were  ameliorated  by  injection  of 
morphine. 

The  second  day  after  operation  (December  2d)  the  condition  of  patient 
and  wound  were  relatively  excellent.  Pulse  96.  The  circulation,  sensibility 
and  motility  of  the  limb  normal.  The  pains  had  become  much  less. 

December  10th. — Ten  days  after  the  ligation  of  the  common  iliac  there 
came  a  sudden  haemorrhage  from  the  original  "  ligature  wound  "  of  the 
femoral.  Although  the  bleeding  was  promptly  controlled  by  compression 
of  the  abdominal  aorta  and  of  the  bleeding  point,  the  loss  of  blood  was  great 
and  the  patient  utterly  exhausted.  On  closer  investigation,  it  was  found 
that  the  haemorrhage  came  from  the  peripheral  end  of  the  femoral.  With 
difficulty  isolated  from  the  disintegrated  tissues,  this  was  tied  off  2  cm. 
below  its  divided  end.  But  the  bleeding  remained  unchecked.  It  came  from 
"  three  thin-walled  arteries  about  the  size  of  a  pen-quill,  which  ran  back- 

u  Dr.  Kiimmel.  it  will  be  recalled,  was  the  originator  of  the  Inorgamscher  Yerband. 


COMMON  ILIAC  ARTERY  343 

wards  and  outwards."  Were  these,  perhaps,  the  profunda,  internal  and  ex- 
ternal circumflex  arteries? 

The  following  day  (December  11th)  a  livid  discoloration  of  the  foot  was 
observed.   Temperature  105°  F.  Pulse  144,  dry  tongue,  delirium. 

December  12th. — Pulse  156.  Increase  of  delirium.  Livid  discoloration  to 
the  middle  of  the  leg.  Condition  of  patient  so  bad  as  to  contraindicate 
operation. 

December  13th. — The  gangrene  seemed  demarked  between  the  upper  and 
middle  thirds  of  the  leg.  Pulse  128.  A  transcondyloid  amputation  was  made 
as  expeditiously  as  possible,  and  then  a  reablation  at  a  higher  point  on 
account  of  the  impaired  circulation  in  the  flaps.  Blood  flowed  from  the 
femoral  artery  and  vein,  and  also  from  muscular  vessels.  Gradually,  the 
patient  developed  the  picture  of  a  chronic  pyaemia.  Abscesses  appeared  on 
the  nates  and  left  arm.  Decubitus  developed  over  the  sacrum,  and  in  the 
articulations  of  the  lower  jaw  and  knee.  Ultimately,  the  patient  was  put 
in  the  permanent  bath,  in  which  the  wound  took  on  a  healthy  appearance 
and  showed  a  tendency  to  heal.  From  this  time  the  prolonged  convalescence 
was  uninterrupted. 

March  3d. — Patient  was  able  to  leave  his  bed. 

This  case  and  Clark's  (25)  are  the  only  ones  in  the  antiseptic  period  which 
have  recovered  after  ligation  of  the  common  iliac  for  the  control  of  severe 
haemorrhage.  In  the  whole  literature  of  the  subject  there  is  perhaps  no  case 
more  thrilling.  In  our  collection  of  thirty  cases  of  the  antiseptic  period  only 
eight  belong  to  Group  I.  Of  these,  four  died,  and  one  (Kiimmel's)  nar- 
rowly escaped  death.  Of  the  remaining  three,  Czerny's  belongs  only  tech- 
nically to  Group  I,  for  the  ligation  of  the  common  iliac  was  made  in  the 
course  of  an  operation  for  the  removal  of  tuberculous  glands  to  control  slight 
bleeding  from  some  artery  torn  off  close  to  its  parent  trunk  in  the  course  of 
the  dissection. 

In  Meyer's  case,  very  briefly  reported,  it  is  not  stated  that  the  haemorrhage 
was  severe. 

The  haemorrhage  in  Clark's  case,  however,  was  to  the  point  of  collapse. 

6.  (Group  II.)  Schonborn,  Karl.  Ligation  of  the  right  common  iliac 
for  aneurism  of  the  internal  and  external  iliac  arteries.  Recovery.  Cure  of 
the  aneurism.    (Setter.   Zentralblatt  f.  Chirurgie,  1884,  p.  160.) 

Male,  aet.  75.  Difficulty  in  walking  beginning  in  January,  1882,  gradu- 
ally increased  until,  in  October  of  the  same  year,  patient  was  unable  to  step 
on  his  right  foot.  About  this  time,  there  was  noticed  in  the  region  of  the 
right  groin  a  tumefaction  which  rapidly  increased  in  size,  and  was  at  first 
considered  to  be  an  abscess  having  origin  in  a  bone  of  the  pelvis. 

In  January,  1883,  an  aspirating  needle  was  introduced  through  which 
"  neither  blood  nor  pus  "  escaped.  As  the  swelling  increased,  it  manifested 
itself  in  the  gluteal  region.  At  last  the  pain  became  so  great  that  there  was 
no  relief  night  or  day,  except  with  the  use  of  chloral  or  morphine. 

Examination. — Patient  seemed  robust  for  his  years,  and  his  general  con- 
dition was  good.    He  could  bear  no  weight  on  his  right  foot,  nor  walk  at 


344  LIGATION  OF 

all  without  firm  support.  Heart  and  palpable  arteries  were  apparently 
normal.  In  the  right  iliac  fossa  a  strong  pulsation  could  be  felt.  On  careful 
inspection  a  slight  swelling  was  observed  in  the  right  supratrochanteric 
region  which,  fading  off  towards  the  right  groin,  extended  behind  and  below 
the  lower  edge  of  the  gluteal  musculature.  Above,  it  approached  the  crest  of 
the  ilium,  and  inwards  the  pubic  symphysis.  Throughout  its  entire  extent, 
rhythmic  pulsation  could  be  seen  and  felt.  On  auscultation  a  systolic  bruit 
isochronic  with  the  pulse  was  heard.  In  the  posterior  tibial  artery  a  dis- 
tinct pulse  could  be  felt.  Examination  by  rectum  revealed  nothing 
anomalous. 

Diagnosis. — Aneurism  in  the  neighborhood  of  the  common  iliac,  quite 
surely  of  a  large  vessel,  probably  of  the  internal  and  also  of  the  external 
iliac.  Ligation  of  the  common  iliac  artery  was  determined  upon  as  nothing 
less  formidable  could  be  done  with  any  prospect  of  success. 

Operation. — May  2,  1883.  Prof.  Schonborn.  Thymol  spray.  An  incision, 
34  cm.  long,  concave  upwards,  was  made  from  the  inner  third  of  Poupart's 
ligament  to  the  lower  border  of  the  twelfth  rib.  The  artery,  exposed  in  the 
extraperitonaeal  manner,  had  an  astonishingly  transverse  course,  and  was 
acutely  bent  on  itself.  Its  wall  seemed  softened.  A  catgut  ligature  was  ap- 
plied. It  developed,  on  further  examination,  that  the  aneurism  had  its 
origin  in  the  right  hypogastric  (internal  iliac),  and  extended  over  into  the 
external  iliac  artery.  Both  vessels  gave  evidence  everywhere  of  atheromatous 
changes.  At  the  moment  of  tying  the  ligature  the  rate  of  the  pulse  was 
increased  from  60  to  75,  and  in  three  minutes,  to  80  beats.1*  There  was 
complete  arrest  of  pulsation  in  the  arteries  peripheral  to  the  ligature.  The 
ends  of  the  ligature  were  cut  short,  drains  carried  to  the  artery  an;: 
where,  the  wound  was  sutured  and  covered  with  a  Lister  dr—  :  with- 

standing the  precautions,  the  wound  broke  down  and  suppurated  every- 
where, except  at  the  ends  and  about  the  ligature.  Xecrosis  of  the  fascia  and 
skin  necessitated  numerous  incisions  and  drainage. 

The  ligation  exerted  no  manifest  influence  upon  the  limb  except  the 
blocking  of  the  pulse.  The  temperature  of  the  skin  of  the  foot,  which  seemed 
slightly  less  than  on  the  opposite  side  for  ten  days,  remained  normal 
thereafter. 

Pains  in  the  extremity  were  severe  at  first,  but  gradually  disappeared 
altogether.  The  healing  of  the  wound  was  slow,  accompanied  by  fever  and 
the  separation  of  necrotic  masses. 

August  2d. — Three  months  after  the  operation,  the  wound  was  healed  and 
the  patient  discharged.  The  aneurismal  swelling  had  become  considerably 
smaller.  Pulsation  neither  in  it  nor  in  the  posterior  tibial  was  to  be  felt. 

ember,  188S. — Six  months  after  the  operation  patient  stated  in  a 
letter  that  he  was  quite  well,  and  able  to  walk  with  a  cane. 

?.  (Group  I.)  Kiimmel,  H.  Aneurism  of  the  right  inguinal  region  and 
the  calf.  Ligation  of  the  external  iliac.  Secondary  haemorrhage.  Ligation 
of  the  right  common  iliac.  Death  in  twelve  hours.    {I.  c,  p.  103.) 

Female,  aet.  21.  Admitted  to  the  medical  division  of  the  hospital  for 
articular  rheumatism  and  peliosis  rheumatica.    Developed  aortic  stenosis 

"  Compare  with  observation  in  Fluhrer's  case  in  which  the  heart's  action  was  slowed. 


COMMON  ILIAC  ARTERY  345 

and  insufficiency.  In  the  further  course  of  the  disease  a  pulsating  tumor, 
the  size  of  a  walnut,  and  causing  great  pain,  appeared  in  the  right  groin  in 
the  region  of  the  anterior  crural  nerve;  a  short  time  thereafter,  a  diffuse, 
tense,  pulsating  swelling  in  the  muscle  of  the  calf  was  observed.  For  both 
the  diagnosis  of  aneurism  was  made. 

The  condition  of  the  patient  was  so  bad  that  an  operative  procedure  was 
not  contemplable,  especially  as  the  multiplicity  of  the  aneurisms  indicated 
general  arterial  disease. 

The  patient's  strength  continuously  failing,  there  occurred  a  rupture  of 
the  aneurism  in  the  calf  followed  quickly  by  extensive  gangrene  of  the  soft 
parts  of  the  leg. 

December  5,  1883. — The  skin  and  the  disintegrated  tissues  underlying 
it  gave  way  and,  thereupon,  there  followed  a  severe  haemorrhage.  Although 
this  was  controlled  by  a  promptly  applied  Esmarch  bandage,  the  already  ex- 
hausted patient  became  almost  pulseless  as  she  was  brought  to  the  operating 
table. 

As  it  was  impossible  to  check,  in  loco,  the  bleeding,  there  remained  only 
the  alternatives  of  amputation  above  the  knee  or  ligation  of  the  main 
arterial  stem.  Amputation  seemed  too  serious  a  procedure.  Furthermore, 
it  was  feared  that  rupture  of  the  aneurism  in  the  groin  might  be  brought 
about  by  ligation  of  the  femoral  artery  below  it.  Hence  the  external  iliac 
was  ligated  above  the  upper  aneurism  in  order  to  cut  the  circulation  off 
from  this  as  well  as  from  the  ruptured  tissues  in  the  calf.  Pulsation  in  the 
groin  ceased,  and  the  aneurismal  sac  collapsed  completely.  On  removal  of 
the  Esmarch  bandage,  there  was  no  return  of  the  bleeding  in  the  leg. 
Masses  of  clots  and  necrotic  tissue  were  removed  from  the  calf,  and  the 
great  hole  cleaned  out  and  stuffed  with  sublimate-gauze.  In  two  hours 
there  was  sudden  profuse  bleeding  from  the  calf  and,  coincident  with  this, 
a  tense  refilling  of  the  aneurism  above,  and  reappearance  of  its  pulsation. 

Again,  and  in  worse  condition  than  ever,  the  patient  was  placed  on  the 
operating  table.  The  common  iliac  was  ligated  extraperitonaeally,  with  cat- 
gut, about  3  cm.  below  the  aortic  bifurcation.  The  operation  was  performed 
in  15  minutes  and  without  anaesthetic.  Infusion  of  800  c.  c.  of  salt  solution. 
Death  in  12  hours. 

Autopsy. — Aneurism  of  a  branch  of  the  profunda.  The  posterior  tibial 
artery  emptied  into  the  gangrenous  cavity  of  the  musculature  of  the  calf. 
A  small  aneurism  of  the  right  posterior  cerebral  artery.  Insufficiency  and 
stenosis  of  the  aortic  valves,  and  in  lesser  degree  of  the  mitral. 

This  case  has  no  bearing  on  either  the  mortality  or  the  occurrence  of  gan- 
grene after  ligation  of  the  common  iliac.  Haemorrhage,  unpreventable  in 
an  already  exhausted  patient,  was  the  immediate  cause  of  death. 

8.  (Group  I.)  Gouley,  John  W.  S.  Ligation  of  the  right  common  iliac 
for  diffuse  aneurism  of  the  external  iliac  artery.  Death  from  pyaemia  on  the 
twenty-first  day.  Beginning  gangrene.  (New  York  Med.  Jour.,  1885, 
February  28,  p.  239.) 

Male,  aet.  22.  Admitted  to  Bellevue  Hospital,  New  York,  October  8,  1871, 
for  a  painful  pulsating  tumor  of  the  right  inguinal  and  iliac  regions. 

History. — About  two  years  before  admission  a  heavy  barrel  rolling  against 
him  inflicted  a  contusion  in  the  neighborhood  of  the  right  groin.   Soon  after 


346  LIGATION  OF 

this  injury  he  contracted  urethritis  and  a  chancre.  These  were  followed  by 
an  enlargement  of  an  inguinal  gland  which  subsided  without  suppuration. 
No  constitutional  symptoms  ensued  so  far  as  could  be  ascertained. 

Nine  months  before  entering  the  hospital  he  had  noticed  a  tumor  just 
above  Poupart's  ligament  on  the  right  side.  Three  months  later  he  observed 
for  the  first  time  that  it  pulsated.  It  was  then  about  as  large  as  a  hen's  egg. 
The  man  continued  to  work  at  heavy  labor,  although  the  tumor  was  rapidly 
increasing  in  size  and  gave  him  great  pain,  of  a  burning  character,  and 
chiefly  in  the  course  of  the  anterior  crural  nerve. 

Examination. — There  was  a  large,  pulsating,  elastic  tumor  which  ex- 
tended six  inches  above  and  two  inches  below  Poupart's  ligament,  and  to 
within  two  and  one-half  inches  of  the  median  line.  Over  it  a  bellows  mur- 
mur was  distinctly  heard.  The  integument  overlying  the  swelling  was  dark 
colored  and  oedematous.  It  was  thought  that  slight  pulsation  could  be  felt 
in  the  right  anterior  tibial,  but  not  in  the  femoral  or  posterior  tibial  arteries. 

Operation,  October  12,  1871. — A  curvilinear  incision,  nine  inches  long, 
beginning  above  at  the  tenth  rib,  was  carried  through  all  the  structures  of 
the  abdominal  wall  except  the  peritonaeum.  This  was  reflected  upwards,  and 
the  spatula  which  had  been  used  as  retractor  by  Valentine  Mott  in  the  per- 
formance of  the  same  operation  was  on  this  occasion  held  by  Dr.  A.  B.  Mott, 
his  son,  who  assisted  Dr.  Gouley.  The  Mott  artery-needle  was  also  employed 
to  carry  the  stout  silk  ligature  with  which  the  common  iliac  was  tied. 
Pulsation  in  the  tumor  immediately  ceased.  The  operation  required  only 
thirty-two  minutes. 

October  13th. — The  tumor  had  softened  and  the  pain  vanished.  The  tem- 
perature of  the  limb  on  the  operated  side  was  found  to  be  higher  than  on 
the  other. 

October  11+th. — During  the  night  the  patient  had  a  sudden  attack  of 
diarrhoea.   This  was  checked  by  morphia. 

October  16th.— Pulse  112;  temperature  102.7°  F. 

October  17th. — "The  tumor  began  to  show  signs  of  rupture";  its  wall 
at  the  lower  portion  had  become  extremely  thin  and  the  overlying  integu- 
ment gangrenous. 

October  22d. — "  Dark  tarry  blood  began  to  ooze  from  the  sac  through  a 
small  opening,  and  the  sac  was  floating,  as  it  were,  in  a  pool  of  pus." 

October  26th.— Pulse  120;  temperature  102°  F.  Dr.  Gouley  "cut  short 
the  slow  spontaneous  enucleating  process  by  introducing  a  finger  and  sweep- 
ing around  that  part  of  the  sac  which  was  out  of  sight,  and  at  the  same  time 
removed  portions  of  sloughy  muscular  tissue."  After  the  sac  had  come  away 
he  could  "  with  the  finger  still  in  the  cavity,  feel  the  bladder." 

April  27th  and  28th. — Chills  and  bed-sore.  Placed  on  water-bed.  Pulse 
140 ;  temperature  103°  F. 

October  29th. — Patient  complained  of  intense  pain  in  the  heel  and  foot 
of  the  affected  side.  Sensation  was  absent  in  these  parts,  and  their  surface 
was  cold. 

October  81st. — Ecchymosis  observed  about  the  right  ankle.  The  pain 
had  extended  up  into  the  leg  and  was  very  intense.   Chills. 

November  1st. — "  The  ecchymosis  had  greatly  increased." 

November  2d. — Death. 


COMMON  ILIAC  AETEEY  347 

Autopsy. — "  The  ligature  lay  loose  in  the  wound.  The  primitive  iliac 
artery  was  completely  obliterated.  Nearly  the  whole  of  the  external  iliac 
had  sloughed  away  with  the  sac,  leaving  less  than  an  inch  of  its  lower 
extremity,  which  was  entirely  closed.  There  was  a  pelvic  abscess  which 
involved  the  psoas  muscle.  The  femoral  and  iliac  veins  were  free  from 
thrombus." 

Epicrisis. — Dr.  Gouley  made  the  following  wise  comment :  "  It  seems  to 
me  that  if  I  had  carried  out  my  intention  of  freely  opening  the  sac,  the 
chances  of  recovery  would  have  been  greatly  increased,  and  that  this  proce- 
dure for  which  we  had  such  strong  warrant,  and  which  in  itself  is  so  simple, 
so  philosophical,  and  therefore  so  eminently  surgical,  should  be  more  insisted 
upon  than  it  has  been  of  late  years."  The  patient  "  succumbed  from  pyaemia 
solely  because  a  great  bag  of  dead  decomposing  blood  was  retained  in  his 
flank.  If  after  ligature  of  the  main  artery  the  sac  had  been  freely  opened 
and  the  clots  extracted,  and  the  cavity  filled  with  lint,  I  am  sure  that  the 
risk  of  this  expedient  would  have  been  infinitely  small  as  compared  with 
the  expectant  plan  which  was  so  unfortunately  adopted." 

The  signs  of  gangrene  (ecchymoses)  which  developed  just  before  death 
were  due,  of  course,  in  part  to  the  enfeebled  action  of  the  heart,  and  prob- 
ably also  to  the  blocking  of  important  anastomotic  arteries  communicating 
with  and  in  the  immediate  neighborhood  of  the  necrotic  sac. 

9.  (Group  II.)  Jameson,  L.  S.  Ligation  of  the  right  common  iliac  for 
aneurism  of  the  external  iliac  artery.  Recovery.  Cure  of  aneurism.  (Lancet, 
Lond.,  1886.   March  6,  p.  444.) 

Female,  aet.  28.  Admitted  to  Kimberly  Hospital,  Cape  Colony,  April  20, 
1885. 

Eleven  months  before  admission  she  noticed  a  small  swelling  the  size  of 
a  nut  in  the  right  groin.  This  gradually  enlarged  during  the  following  six 
months,  without  causing  pain,  to  the  size  of  an  apple.  Then,  the  tumor 
enlarging  rapidly  and  becoming  softer,  she  noticed  a  "  beating  "  sensation 
in  the  swelling,  and  pain  and  numbness  down  the  leg. 

Examination. — Above  Poupart's  ligament  was  an  oval  pulsating  swelling 
as  large  as  the  head  of  a  new-born  child,  which  extended  outwards  to  within 
an  inch  of  the  anterior  superior  spine,  inwards  to  the  mid-line  and  upwards 
to  the  umbilicus.  The  upper  portion  of  the  tumor  was  solid;  below  it  was 
soft;  the  skin  of  a  deep  purple  color,  looked  as  if  it  might  rupture  on  the 
slightest  provocation.  There  was  marked  swelling  of  the  whole  of  the 
right  limb.  Pulsation  in  the  posterior  tibial  artery  was  "  practically " 
imperceptible. 

Operation,  April  21st. — The  tumor  was  so  large  that  it  was  deemed  im- 
possible to  expose  the  right  common  iliac  by  operating  on  the  right  side. 
The  incision,  consequently,  was  made  on  the  left  side ;  the  left  common  iliac 
was  located  extraperitonaeally  and  traced  up  to  the  bifurcation  of  the  aorta. 
The  right  common  iliac,  well  overlapped  by  the  aneurism  which  apparently 
had  its  origin  in  the  external  iliac,  was  ligated  with  stout  carbolized  silk. 
Pulsation  in  the  aneurism  ceased  at  once. 


348  LIGATION  OF 

The  following  day,  April  22d,  slight  pain  and  restlessness.  Temperature 
a.  m.  101°  F. ;  p.  m.  101.6°  F.  The  wound  showed  increased  discoloration 
at  its  lower  part. 

April  28d. — Discharge  of  bloody  serum  from  wound.  No  pain.  No  ab- 
dominal distension. 

April  28th. — Temperature  99°  F.  No  pain.  Superficial  and  deep  stitches 
removed.   Some  gaping  of  the  superficial  wound. 

April  29th. — Pain  in  the  leg.   Temperature  normal. 

May  12th. — Bed  sore  over  sacrum,  which  was  present  on  admission. 
Patient  remained  in  the  hospital  for  three  months  longer,  the  tumor  dimin- 
ishing slowly  in  size. 

October  15th. — On  deep  pressure  the  tumor,  quite  solid,  measured  2|  x  3 
inches.  Both  the  knee  and  the  hip  were  considerably  flexed,  and  patient  got 
about  with  difficulty.   Her  health  was  perfect. 

The  operation  was  performed,  presumably  without  antiseptics,  for 
Mr.  Jameson  seems  to  have  acted  on  the  suggestion  given  him  seven  years 
before,  as  he  was  about  to  depart  for  Cape  Colony,  not  to  supply  himself 
with  them.  Mr.  John  Marshall  had  said  to  him,  "  You  are  going  to  an  anti- 
septic climate  and  don't  require  them."  Mr.  Jameson  remarks  that  this 
opinion  had  since  been  fully  justified.  Grave  injuries,  such  as  compound 
fractures,  which  in  London  would  have  made  amputation  imperative,  healed 
at  Cape  Colony  in  a  marvellously  short  time  under  some  simple  wet  dress- 
ing, such  as  boracic  lint. 

10.  (Group  II.)  Fluhrer,  W.  F.  Transperitonaeal  ligation  of  the  left 
common  iliac  artery  for  aneurism  of  the  external  iliac.  Death  on  the  seventh 
day  from  acute  nephritis.  (New  York  Med.  Record,  1886,  October  26th, 
p.  454.) 

Male,  colored,  aet.  35.   Admitted  to  Mount  Sinai  Hospital,  May  3,  1886. 

Four  years  before  admission  patient  contracted  syphilis.  In  September, 
1885,  he  observed  that  the  left  lower  limb  and  groin  became  "  suddenly 
swollen  and  painful."  Once  the  swelling  in  the  groin  was  so  great  that  he 
could  hardly  flex  the  thigh.  Since  then  the  swelling  diminished,  but  at  no 
time  did  it  disappear. 

Ten  weeks  before  admission,  the  patient  noticed  a  small,  deeply  seated 
pulsating  tumor  in  the  left  groin.  This  steadily  increased  in  size  and  in 
the  force  of  its  pulsations.  The  patient  had  lost  twenty  pounds  in  weight. 
He  appeared  to  be  only  fairly  vigorous. 

Examination. — The  tumor  in  the  left  groin  was  hardly  noticeable  on 
inspection,  but  on  palpation  it  was  found  to  be  about  two-thirds  the  size  of 
a  fist.  From  Poupart's  ligament  it  extended  upwards  to  a  point  about  mid- 
way between  the  symphysis  and  the  umbilicus;  inwards  it  reached  almost 
to  the  mid-line.  Its  pulsation  was  expansile,  and  accompanied  by  a  faint 
systolic  bruit.  Pulsation  in  the  left  femoral  artery,  weaker  than  in  the  right, 
could  be  felt.  The  circulation  of  the  limb  on  the  affected  side  was  good. 
There  was  no  visible  dilatation  of  the  veins.  The  visceral  examination  re- 
vealed nothing  abnormal.  The  urine's  specific  gravity  was  1020,  and  in 
other  respects  it  was  normal. 


COMMON"  ILIAC  ARTEEY  349 

Diagnosis. — Aneurism  involving  the  whole  extent  of  the  external  iliac 
artery. 

The  operation  (May  20th)  was  conducted  with  thorough  antiseptic  pre- 
cautions. The  common  iliac  artery  was  tied  off  about  one-quarter  of  an 
inch  below  the  bifurcation  of  the  aorta  with  a  silk  ligature,  which  had  been 
boiled  for  two  hours  in  a  5  per  cent  solution  of  carbolic  acid.  About  one 
minute  after  the  ligation  a  slowing"  of  twelve  or  fifteen  beats  was  ob- 
served by  Dr.  Purroy,  who  was  taking  the  radial  pulse.  Patient  reacted 
well  from  the  operation  which  had  required  two  hours. 

May  21st. — He  complained  of  pains  in  the  toes  of  the  left  foot.  The  cir- 
culation was  "  returning  in  the  three  lower  toes."  The  urine  contained 
albumen,  hyaline  casts,  and  some  blood  corpuscles. 

May  23d. — The  circulation  was  "good  in  the  foot  and  toes."  A  pulse 
could  be  felt  in  the  dorsalis  pedis  artery.  Patient  was  restless.  Urine  was 
heavily  charged  with  albumen,  and  contained  hyaline  casts  in  great  num- 
bers, and  some  blood  corpuscles. 

May  2Jfth.— Pulse  140;  temperature  102.6°  F. 

May  26th. — Patient's  condition  was  grave.  He  was  sluggish  and  unable 
to  swallow. 

May  27th. — Delirium.  Died  at  1  p.  m. 

Autopsy. — The  abdominal  wound  had  healed  by  first  intention.  The 
aneurism  extended  the  whole  length  of  the  external  iliac  artery.  The  sac 
showed  a  tendency  to  form  pouches.  It  was  filled  with  a  solid  clot.  The 
femoral  vein  was  plugged  with  a  firm,  hard  thrombus.  The  external  iliac 
vein  was  impervious  and  lost  upon  the  surface  of  the  aneurism.  "  This 
condition  of  the  veins  accounts  for  the  comparatively  sudden  oedema  of  the 
lower  extremity  and  groin  in  the  early  history  of  the  disease."  The  ligature 
had  been  applied  three-fourths  of  an  inch  from  the  aneurism  and  one-fourth 
of  an  inch  below  the  bifurcation  of  the  aorta,  and  precisely  at  the  point  of 
crossing  of  the  ureter.  The  common  iliac  vein  lay  exactly  behind  the  artery. 
There  was  an  aneurism  of  the  aorta  which  began  at  the  bifurcation  and 
extended  upwards  for  four  inches.  Calcified  plates  could  be  felt  in  the 
walls  of  the  aneurism.  In  the  sac  was  a  clot  which  contrasted  strongly  with 
that  which  filled  the  aneurism  of  the  external  iliac.  The  former  was  pale, 
firm,  laminated,  and  appeared  adherent  in  places  to  the  wall  of  the  sac; 
it  did  not  wholly  obstruct  the  lumen  of  the  aorta.  "  The  remaining  opera- 
tive conditions,"  wrote  Dr.  Fluhrer,  "that  favored  the  development  of 
nephritis  were  the  prolonged  and  complete  anaesthetization  and  the  change 
in  the  renal  circulation."  (Italics  mine.)  "  If  the  shutting  off  of  the  main 
arterial  blood  supply  to  one-fourth  of  the  body  caused  such  a  disturbance  of 
the  general  circulation  as  to  be  noticed  by  a  slowing  and  increase  in  the 
volume  of  the  radial  pulse,  surely  there  must  have  been  a  more  intense  effect 
upon  the  renal  circulation,  not  only  from  the  nearness  of  the  renal  arteries 
to  the  place  of  ligation,  but  also  from  the  presence  of  the  clot-containing 
aneurism  of  the  aorta  reaching  to  within  two  inches  of  their  origin,  which 

"Compare  with  Schonborn's  case  in  which  the  pulse  was  accelerated  fifteen  to 
twenty  beats  on  tying  the  common  iliac. 


350  LIGATION  OF 

must  have  been  an  obstacle  to  the  free  delivery  of  blood  to  the  lower 
channels."  " 

11.  (Group  II.)  Smith,  Thos.  Ligature  of  the  right  common  iliac  artery 
with  kangaroo  tendon  for  a  large  fusiform  ileofemoral  aneurism;  yielding 
of  the  knot;  re-ligature  with  silk;  gangrene  of  the  limb.  (Trans,  of  the 
Clin.  Soc.  of  London,  1887,  xx,  29.) 

Male,  aet.  52.  Admitted  to  St.  Bartholomew's  Hospital,  October  14,  1885. 
An  aneurism  of  the  right  external  iliac  artery  extended  from  a  point  mid- 
way between  the  umbilicus  and  crural  arch  into  the  upper  part  of  the  thigh. 
The  right  thigh  was  much  swollen,  measuring  3  inches  more  than  the  left. 

October  22d. — Ligation  of  the  common  iliac  artery  just  above  the  aneu- 
rism with  kangaroo  tendon.  The  vessel  at  the  point  of  ligature  was  very 
large,  and  erroneously  supposed  to  be  the  external  iliac.  The  ligature  was 
cut  short  and  the  wound  drained. 

October  23d. — Pulsation,  as  forcible  as  before  the  operation  of  the  previ- 
ous day,  returned  in  the  aneurism.  Fearing  that  the  knot  had  slipped,  the 
wound  was  opened  and  the  common  iliac  religated  with  two  ligatures  of 
carbolized  silk.  The  knot  of  the  original  ligature  was  not  obviously  loose, 
but  the  point  of  an  aneurism  needle  could  be  inserted  between  the  kangaroo 
tendon  and  the  vessel.  The  silk  ligatures  were  cut  short  and  the  wound 
drained. 

October  21+th. — "  No  pulsation  in  the  sac.  Leg  warm,  but  darkish  in 
color." 

October  25th. — "  Pulsation  evident  in  sac;  leg  mottled  and  purple  .... 
colder  and  insensible;  thigh  discolored." 

October  26th. — "Pulsation  in  the  sac  increasing;  condition  of  the  whole 
limb  much  improved,  as  regards  color  and  temperature."  Was  this  perhaps 
due  to  the  fact  that  the  circulation  in  the  aneurism  was  being  restored  ? 

October  27th. — "  Pulsation  in  the  sac  continues,  a  slough  forming  in  the 
calf." 

October  28th. — "  Pulsation  continued  in  sac,  leg  and  foot  becoming  blue. 
Pulse  120;  temperature  103°  F." 

October  30th. — "Gangrene  seems  limited  to  foot  and  front  part  of  leg; 
sac  still  pulsates." 

October  81st. — "  Pulsation  in  sac  less,  and  signs  of  a  line  of  demarcation; 
patient's  general  condition  a  little  better." 

"  During  the  next  two  days  the  line  of  demarcation  became  evident,  and 
on  November  2d  amputation  was  performed  just  above  the  condyles." 

The  patient  died  November  3d. 

15 1  quite  concur  with  this  conclusion  of  Dr.  Fluhrer  as  to  the  possible  effect  upon 
the  function  of  the  kidneys  of  obstruction  of  the  arterial  circulation  below  the  renal 
arteries,  and  would  refer  the  reader  to  a  recent  article  by  my  former  assistant, 
Dr.  Gatch  (Annals  of  Surgery,  July,  1911,  liv,  p.  30),  in  which  this  question  is 
considered.  We  observed  in  two  cases  that  partial  occlusion  of  the  aorta  in  the  human 
subject  exerted  a  sudden  and  profound  effect  upon  the  renal  findings.  Dr.  Gatch's 
careful  study  of  these  cases  stimulated  him  to  make  experiments  upon  dogs  and  to 
determine  the  effect  upon  the  kidneys  of  aortic  obstruction  in  the  healthy  animal. 


COMMON  ILIAC  ARTERY  351 

Autopsy. — "  No  general  peritonitis,  but  some  matting  of  the  coils  of 
intestines  in  the  immediate  neighborhood  of  the  wound."  Thrombosis  of 
the  external  iliac,  common  femoral  and  profunda  veins,  and  of  the  internal 
iliac,  common  femoral,  superficial  femoral  and  profunda  arteries.  The  sac 
of  the  aneurism  was  quite  filled  with  a  firm  laminated  clot. 

12.  (Group  II.)  Lucas,  Clement.  Transperitonaeal  ligation  of  the  com- 
mon iliac  artery  for  aneurism  of  the  external  iliac."  "Successful."  (Brit. 
Med.  Jour.,  1892,  November  26th,  p.  1163.   W.  Mitchell  Banks.') 

Mr.  Banks  makes  the  following  brief  reference  to  a  case  of  Mr.  Clement 
Lucas :  "  Mr.  Sheild's  letter  is  obviously  eliciting  the  necessary  experience, 
as  evidenced  by  Mr.  Clement  Lucas*  communication,  in  which  he  reminds 
us  of  his  successful  case  of  ligature  of  the  common  iliac  through  the  peri- 
tonaeum for  aneurism  of  the  external  iliac  artery  done  three  and  a  half 
years  ago." 

13.  (Group  I.)  Meyer,  Willy.  Ligation  of  the  common  iliac  artery  for 
secondary  haemorrhage  incident  to  ligation  of  the  internal  iliac  arteries  for 
enlargement  of  the  prostate  gland.  Recovery.  (Annals  of  Surgery,  1894, 
xx,  p.  44.) 

Male,  aet.  55,  admitted  to  the  German  Hospital,  New  York,  October, 
1893,  for  enlargement  of  the  prostate  gland. 

October  5th. — Ligation  of  both  internal  iliac  arteries  (Bier),  extraperi- 
tonaeally,  by  Dr.  Meyer.  In  the  act  of  dividing  the  sheath  of  the  left  internal 
iliac,  the  point  of  the  scalpel  pricked  the  artery.  The  haemorrhage  was 
checked  by  the  finger  of  an  assistant  on  the  common  iliac,  while  Dr.  Meyer 
ligated  the  artery  above  and  below  the  wound  in  the  vessel.  He  then  divided 
the  internal  iliac  between  the  ligatures.  The  haemorrhage  ceased,  but  "  sud- 
denly it  again  set  in  in  a  most  alarming  way."  The  common  iliac  being 
once  more  compressed  by  an  assistant's  finger,  it  was  seen  that  the  ligature 
(catgut)  had  slipped  from  the  proximal  stump  of  the  internal  iliac. 
"  Further  attempts  at  properly  placing  a  ligature  proving  futile,  and  bleed- 
ing continuing,"  a  long  artery  clamp  was  placed  on  each  end  of  the  divided 
vessel.  These  were  allowed  to  remain  in  the  wound,  being  carefully  packed 
about  with  gauze. 

The  operation  on  the  right  side  was  greatly  facilitated  by  the  Trendelen- 
burg position.  The  right  internal  iliac  was  tied  in  two  places  with  ligatures 
of  catgut,  and  the  artery  was  not  divided.  This  wound  was  closed,  layer  by 
layer,  without  drainage. 

On  the  fifth  day,  the  clamps  on  the  stumps  of  the  left  internal  iliac  were 
removed.  The  sutured  wounds  had  healed  throughout,  the  track  of  the 
forceps,  of  course,  excepted. 

"  On  the  evening  of  the  twelfth  day,  the  patient  suddenly  noticed  a  hot 
feeling  on  the  left  side;  secondary  arterial  haemorrhage  had  set  in." 
Compression  was  promptly  made  by  a  well-trained  nurse,  then  by  the  house 
surgeon  who  introduced  his  finger  into  the  depths  of  the  bleeding  canal,  and 
awaited  the  arrival  of  Dr.  Meyer,  who  had  been  summoned.  The  patient  was 
placed  in  the  Trendelenburg  posture,  and  the  wound  opened.  Dr.  Meyer 
found  to  his  surprise  that  the  bleeding  came,  not  from  the  internal  iliac,  but 
from  a  hole  in  the  external  iliac  artery.   There  was  a  defect,  evidently  caused 


352  LIGATION  OF 

by  the  pressure  of  a  forceps,  in  the  anterior  wall  of  this  vessel  just  below 
the  bifurcation  of  the  primitive  trunk.  So  the  external  iliac  was  ligated 
below  the  hole,  and  the  common  iliac  above  it.  The  catgut  ligatures  cut 
through  the  latter  twice,  and  hence  a  ligature  of  silk  was  applied  close  to 
the  bifurcation  of  the  aorta. 

"  Soon  after  the  operation,  gangrene  of  the  toes  and  a  part  of  the  metatar- 
sus developed,  which  later  necessitated  irregular  amputation  of  the  anterior 
part  of  the  foot."  The  wound  of  the  foot  being  healed,  the  patient  began  to 
walk  about  and  left  the  hospital  April  28th. 

So  far  as  reduction  in  the  size  of  the  prostate,  and  the  restoration  of  the 
function  of  the  bladder  were  concerned,  the  result  in  the  opinion  of 
Dr.  Me}rer  was  "  encouraging  in  the  extreme."  No  mention  is  made  in  the 
report  of  pain  in  the  limb  following  the  ligation  of  the  common  iliac,  nor 
is  there  any  note  concerning  the  function  of  this  member. 

14.  (Group  II.)  Stevenson,  "VV.  F.  Trans  per  it  onaeal  ligation  of  the  left 
common  iliac  for  diffuse  traumatic  aneurism  of  the  external  iliac  and 
femoral  arteries.  Recovery.  Cure  of  aneurism.  (Lancet,  London,  1896, 
January  25th,  p.  224.  Brigade-Surgeon-Lieutenant-Colonel  W.  F.  Stevenson 
and  Surgeon-Major  H.  I.  Michael.) 

Patient,  aet.  35,  was  a  sergeant  in  the  artillery  stationed  at  Dover  Castle. 
About  October  12,  1895,  patient  slipped  and  fell  with  his  left  leg  under  him. 
He  felt,  at  the  time,  a  sharp  pain  in  the  left  groin,  but  remained  on  duty 
for  a  week.  Admitted  to  hospital,  October  19,  1895. 

Examination. — The  left  leg  was  swollen  and  oedematous,  and  the  super- 
ficial veins  were  distended.  There  was  a  large,  forcibly  pulsating  swelling 
in  the  left  groin  extending  from  one  inch  above  Poupart's  ligament  to  six 
inches  below  it,  and  occupying  almost  the  entire  space  between  the  anterior 
superior  spine  to  the  pubes.  Patient  was  put  to  bed,  his  limb  elevated  and 
bandaged  from  the  foot  to  the  middle  of  the  thigh. 

October  29th. — The  tumor  had  become  larger  and  was  very  painful.  It 
was  decided,  on  consultation,  to  ligate  the  common  iliac  on  the  following 
day.  But  on  the  thirtieth  it  was  found  that  the  tumor  had  become  solid,  and 
that  the  pulsation  had  almost  ceased. 

November  Jfth. — No  pulsation  could  be  felt,  although  a  faint  bruit  was 
still  to  be  heard  at  a  spot  over  the  inner  side  of  the  swelling.  The  leg  was 
much  reduced  in  size,  and  its  temperature  was  "  fairly  good."  Apparently 
spontaneous  cure  was  taking  place  and  the  collateral  circulation  being 
established. 

November  Ufth. — Slight  pulsation  had  reappeared. 

November  15th. — The  picture  had  entirely  changed.  Strong  pulsation 
could  be  felt  all  over  the  tumor,  which  had  enlarged  in  every  direction.  The 
local  condition  was  much  the  same  as  on  admission  to  the  hospital. 

First  operation. — Aseptic  precautions.  Mid-line  incision.  Intestines  were 
lifted  out  of  the  abdominal  cavity.  Ligation,  with  silk,  of  the  left  common 
iliac  artery.  Wound  closed.  Horse-hair  suture  of  the  skin.  Pulsation  in 
the  tumor  ceased  on  tying  the  ligature.  It  was  the  operator's  intention  to 
continue  the  operation  in  order  to  turn  out  the  clots  from  the  sac ;  but  as 
the  light  was  bad  and  the  tumor  flaccid,  further  operative  procedure  was 


COMMON  ILIAC  ARTERY  353 

deferred.  The  patient  made  an  uninterrupted  recovery  from  the  laparotomy, 
his  temperature  at  no  time  being  above  99°  F.  The  circulation  in  the  limb 
was  unimpaired.  The  tumor  slowly  diminished  in  size;  the  skin  over  it 
became  loose  and  wrinkled.   There  was  no  return  of  the  pulsation. 

Second  operation,  December  21st. — Two  and  a  quarter  pounds  of  soft 
blood  clot  were  removed  from  a  huge  cavity  in  the  upper,  inner  aspect  of 
the  thigh,  extending  from  the  bifurcation  of  the  common  iliac  artery  to  the 
central  end  of  Hunter's  canal.  There  was  so  little  haemorrhage  during  this 
operation  that  only  one  ligature  was  required.  The  cavity  was  packed  with 
iodoformized  gauze,  and  allowed  to  heal  by  granulation.  The  circulation  of 
the  leg  was  unimpaired. 

15.  (Group  II.)  McBurney,  Chas.  Ligation  of  the  left  common  iliac 
artery  for  aneurism  of  the  external  iliac.  Recovery.  Cure  of  aneurism. 
(Annals  of  Surgery,  1898,  xxviii,  128.) 

March  9,  1898,  at  a  meeting  of  the  New  York  Surgical  Society, 
Dr.  McBurney  presented  a  young  man,  who,  the  year  before,  after  lifting 
a  heavy  weight,  felt  a  pain  in  the  neighborhood  of  the  left  groin.  A  few 
weeks  later  he  noticed  a  lump  in  that  region,  which  gradually  increased  until 
it  attained  the  size  of  a  closed  fist. 

Examination. — The  circulation  in  the  limb  of  the  affected  side  was  good. 
The  tumor  presented  all  the  characteristics  of  an  aneurism.  It  terminated 
below  at  Poupart's  ligament.  It  was  decided  that  the  ligation  of  the  com- 
mon iliac  was  indicated.  This  operation  was  performed  December  18,  1897, 
transperitonaeally,  and  through  a  long  median  abdominal  incision.  In  order 
to  reach  the  vessel  it  was  necessary  to  lift  out  the  intestines.  On  tying  the 
double  catgut  ligature,  pulsation  in  the  aneurism  ceased,  and  the  sac  rapidly 
diminished  in  size.  The  wound  healed  by  first  intention.  There  were  not 
at  any  time  signs  of  disturbance  of  the  circulation  of  the  limb.  The  patient 
was  discharged  one  month  after  the  operation.  He  was  able  to  work,  but 
still  complained  of  some  weakness  in  the  left  leg  three  months  after  the 
operation.    There  had  been  no  return  of  the  pulsation.  ( 

Dr.  McBurney's  report  of  the  case  is  very  brief.  No  mention  is  made  of 
pains  in  the  leg,  in  the  days  immediately  following  the  operation. 

16.  (Group  II.)  Bryant,  Jos.  D.  Ligation  of  the  right  common  iliac 
artery  for  aneurism  of  the  external  iliac.  Died  in  three  days.  (Annals  of 
Surgery,  1898,  xxviii,  128.) 

In  the  discussion  of  McBurney's  case,  Dr.  Bryant  stated  that  about  five 
years  before,  at  St.  Vincent's  Hospital,  he  ligated  the  right  common  iliac 
for  the  cure  of  a  large  aneurism  of  the  external  iliac  artery,  which  had  been 
present  for  a  long  time  and  caused  the  patient  great  distress. 

He  experienced  some  difficulty  in  locating  the  artery,  as  it  was  displaced 
considerably  to  the  right  side.  On  account  of  the  anomalous  position  of  this 
artery  the  left  common  iliac,  correspondingly  misplaced,  narrowly  escaped 
the  ligation.  The  patient  was  in  bad  condition,  and  survived  the  operation 
only  three  days. 

"At  the  autopsy  it  was  found  that  the  aorta  rested  and  bifurcated  on 
the  right  instead  of  the  left  side  of  the  lumbar  vertebrae."   This  anomaly, 
Dr.  Bryant  said,  occurs  in  about  5  per  cent  of  the  cases. 
24 


354  LIGATION  OF 

17.  (Group  II.)  Von  Biingner.  Ligation  of  the  left  common  iliac  artery 
for  aneurism  of  the  ischiadic  artery.  Excision  of  sac,  gangrene.  Death. 
(E.  v.  Varendorff.  Ueber  die  Verletzungen  und  Aneurysmen  der  Arteria 
glutea  und  ischiadica.   Inaug.   Dissertation,  Marburg,  1899.) 

Female,  aet.  66,  admitted  to  the  Landkrankenhaus,  June  11,  1898. 

Anamnesis. — Suffered  from  rheumatism  ten  years  ago,  and  since  then 
from  varicose  veins  and  ulcers  of  the  leg ;  otherwise,  has  always  been  well. 

In  November,  1897,  she  noticed,  on  placing  her  hand  upon  the  left  hip, 
a  very  distinct  pulsation  and  heaving  under  it.  Since  that  time  a  swelling 
forming  in  the  gluteal  region  has  been  slowly  but  appreciably  increasing  in 
size,  and  assuming  more  and  more  the  hemispherical  form.  Presently  pains 
were  felt  starting  in  the  tumor  and  radiating  down  the  back  of  the  thigh  to 
the  toes.  Finally  the  pains  became  so  severe  as  to  be  uncontrollable  by 
morphia. 

For  the  past  few  weeks  she  could  lie  only  on  the  unaffected  side,  and  with 
thigh  and  knee  slightly  flexed. 

Status  Praesens. — Large,  robust  woman.  Area  of  cardiac  dullness  slightly 
increased  to  the  left  and  right.  A  blowing,  mitral,  systolic  murmur.  The 
second  pulmonary  sound  accentuated.  Atheromatous  arteries.  Pulse  88-96, 
small  and  soft.  Urine  normal.  Highly  developed  varices.  Scars  of  healed 
leg-ulcers.  On  the  left  buttock  is  a  tumefaction  as  large  as  the  hand  of  a 
child  which,  synchronous  with  the  pulse  wave,  rhythmically  rises  and  falls. 
The  tumor  is  23  cm.  high  by  19  cm.  broad.  With  the  hand  one  feels  very 
distinct  pulsations,  and  constates  that  these  do  not  become  stronger  when 
the  tumor  is  pressed  into  the  buttock.  The  tension  in  the  tumor  is  so  great 
that  fluctuation  can  hardly  be  made  out.  A  swishing  bruit  is  to  be  heard 
everywhere  over  the  tumefaction.   Pelvic  examination  negative. 

Diagnosis. — Spontaneous  aneurism  of  the  gluteal  or  sciatic  artery ;  mitral 
insufficiency;  general  arteriosclerosis. 

Operation,  June  llf.,  1898. —  (Prof.  v.  Biingner.)  Patient  on  her  right 
side.  Aneurism  when  exposed  was  blue,  very  tense  and  strongly  pulsating. 
In  the  endeavor  to  tie  all  the  arteries  leading  to  the  aneurism  (Philagrius) 
a  little  tear  in  the  sac  wall  was  made,  and  through  this  there  spurted  a 
powerful  stream  of  blood.  The  haemorrhage  was  checked  by  the  pressure 
of  a  finger.  Attempts  to  close  the  hole  with  suture  and  forceps  were  made 
in  vain,  and  always  attended  with  great  haemorrhage.  So  the  finger  pressure 
had  to  be  relied  upon  while  the  operation  for  the  ligation  of  the  common 
iliac  artery  was  being  conducted,  the  right-sided  position  of  the  patient 
being  continuously  maintained. 

This  position  was  found  to  be  so  advantageous  for  the  exposure  of  this 
artery  that  v.  Varendorf  urgently  recommends  it  as  greatly  facilitating  the 
performance  of  this  operation.  The  external  and  common  iliac  arteries  were 
plainly  visible.  The  internal  iliac  which  could  be  felt  and,  in  its  central 
portion,  seen  was  found  to  be  the  seat  of  a  fusiform  aneurism  throughout 
its  entire  length.  Fearing  to  apply  a  ligature  to  an  artery  so  diseased,  the 
common  iliac  was  tied  as  the  only  alternative.  Immediately  the  pulsation 
and  thrill  ceased  in  the  gluteal  aneurism. 

The  abdominal  wound  was  sutured  and  then,  without  much  difficulty, 
the  collapsed  sac  was  removed  and  all  the  vessels  from  it  ligated.   It  was, 


COMMON  ILIAC  ARTERY  355 

now,  determined  that  the  aneurism  had  its  provenience  in  the  sciatic  artery. 
Bather  troublesome  was  the  tying  off  of  the  afferent  sciatic  artery,  because 
the  sac  extended  through  the  incisura  ischiadica  major  into  the  pelvis.  To 
facilitate  the  extirpation  of  the  sac  its  posterior  wall  was  split.16 

The  sciatic  nerve  was  found  to  be  so  closely  interwoven  with  the  wall  of 
the  sac  that  it  was  thought  to  be  necessary  to  remove  about  three-quarters 
of  the  circumference  of  this  nerve. 

On  the  following  day,  June  15th,  the  patient's  condition  seemed  to  be 
satisfactory.  The  leg  on  the  operated  side  felt  warm,  and  its  sensibility  was 
preserved.  No  mention  is  made  of  pain  in  the  limb. 

June  16th,  p.  m. — Temperature  38.2°,  pulse  142,  and  weak. 

June  17th,  p.  m. — Temperature  38°,  pulse  124.  The  left  foot  and  leg  felt 
cold,  and  sensation  in  them  was  lost.  There  were  many  deep,  blue  spots, 
irregular  in  outline  and  varying  in  size. 

June  18th. — Patient  became  soporific.  The  blue  spots  were  increased  in 
size  and  number.  Without  the  occurrence  of  other  manifestations,  the  patient 
died  at  11  p.  m. 

18.  (Group  II.)  Korte,  W.  Ligation  of  the  right  common  iliac  artery 
for  ruptured  aneurism  of  the  external  iliac.  Consecutive  ligation  of  the 
aorta.  Death.  (Prof.  W.  Korte.  Deutsche  med.  Wochenschrift,  1900, 
xxvi,  717.) 

Male,  aet.  28. 

Anamnesis. — After  an  excessively  wearisome  journey  in  the  mountains 
patient  was  seized  with  severe  pains  in  the  joints.  Simultaneously  there  ap- 
peared nodules  on  the  extremities  which  disappeared  after  taking  iodide 
of  potassium. 

Early  in  March,  1899,  patient  observed  a  painless,  pulsating  swelling 
above  the  flexture  of  the  groin.  After  a  long  bicycle  ride  on  April  1st,  he 
experienced  pain  so  severe  that  he  was  compelled  to  lie  down.  The  right  leg 
could  not  be  used;  the  pains  radiated  down  the  front  of  the  thigh,  and 
acquired  such  intensity  that  he  applied  for  admission  to  the  Stadtisches 
Krankenhaus  am  Urban,  Berlin,  April  15,  1899. 

Status. — A  tall,  lean,  powerful,  anaemic  man.  Temperature  38,  pulse 
100-110,  and  easily  compressible.  The  right  limb  somewhat  oedematous  and 
slightly  flexed  at  the  hip ;  cannot  be  voluntarily  moved.  Passive  movements 
normal. 

Above  Poupart's  ligament,  on  the  right  side,  is  a  pulsating  tumor  the 
size  of  a  large  apple.  The  walls  are  tensely  expanded.  Distinct  thrill  and 
bruit  over  the  tumor,  and  extending  to  the  left  to  within  about  4  cm.  from 
the  mid-line,  and  to  the  right  to  the  outer  edge  of  the  right  rectus  muscle. 
Beyond  these  limits  there  is  a  resistant  mass  which  entirely  fills  the  right 
iliac  fossa,  extends  upwards  to  the  edge  of  the  ribs  and  backwards  to  the 
long  muscles  of  the  spine.  The  pulsating  tumor  extends  above  to  a  point 
midway  between  navel  and  symphysis,  and  below  to  Poupart's  ligament. 
Scarpa's  triangle  is  filled  out  in  such  manner  as  to  press  forward  the  strongly 

16  It  has,  for  many  years,  been  a  favorite  procedure  with  surgeons  to  split,  in 
two  or  in  many  parts,  benign  tumors  otherwise  difficult  of  removal,  (i.  e.,  lipomata 
of  the  back  of  the  neck.) 


356  LIGATION"  OF 

pulsating  femoral  artery.  Per  rectum  a  thickening  of  the  soft  parts  on  the 
right  pelvic  wall  is  appreciable,  and  the  pulsating  tumor  can  be  felt. 

Compression  of  the  aorta  and  of  the  right  common  iliac  arrests  the  pul- 
sation in  the  tumor.  The  heart  is  enlarged  to  the  left.  Over  the  aorta  a 
diastolic  murmur  is  to  be  heard  and  felt.  Eadial  arteries  tortuous.  Urine 
free  from  albumen  and  sugar. 

Diagnosis. — Aneurism  of  the  right  external  iliac,  ruptured;  extensive 
extravasation  of  blood;  aortic  insufficiency  and  perhaps  aneurism  at  the 
beginning  of  the  aorta.  Intraperitonaeal  ligation  of  the  common  iliac  was 
determined  upon.  The  extraperitonaeal  route  was  distinctly  contraindicated 
because  of  the  extravasated  blood. 

Operation,  April  17,  1899. — Ligation  of  the  common  iliac  with  catgut. 
Pulsation  in  the  aneurism  thereupon  ceased.  For  a  few  hours  the  right 
extremity  was  pale,  but  soon  became  warm  and  natural  in  color.  Otherwise 
no  disturbances  of  the  circulation  resulted  from  the  ligation.  In  the  femoral 
artery  a  slight  pulsation  was  discernible.  The  toes  could  be  moved;  sensa- 
tion remained  unchanged.  But  for  three  days  there  were  signs  of  intestinal 
paresis,  nausea,  singultus  and  tympany. 

In  the  washing  of  the  stomach,  great  quantities  of  dark  fluid  containing 
material  resembling  coffee-grounds  were  evacuated,  and  the  first  stools  were 
blackish,  as  if  blood-stained.  It  was  concluded  that  the  subperitonaeal  ex- 
travasation had  either  perforated  the  bowel  at  some  point,  or  that  it  had 
compressed  the  mesenteric  vessels  (of  the  duodenum  or  ascending  colon). 

The  sac  of  the  aneurism  remained  pulseless  and  without  bruit.  The  large 
haematoma  on  the  right  side  did  not,  however,  diminish  in  size  and  con- 
tinued to  cause  distress. 

On  the  second  right  intercostal  space,  alongside  of  the  sternum,  a  pulsa- 
tion, which  could  be  seen  and  felt  became  manifest.  Over  this  area  systolic 
and  diastolic  murmurs  were  heard.  On  the  6th  of  May,  and  afterwards, 
there  were  signs  of  thrombosis  of  the  femoral  vein.  The  general  condition 
of  the  patient  did  not  improve;  he  remained  pale,  his  pulse  became  more 
rapid,  his  temperature  remaining  normal,  and  he  complained  continually 
of  pains  in  the  haematoma,  which  radiated  to  the  sacrum.  The  active  move- 
ments of  the  right  limb  became  more  limited  and,  towards  the  middle  of 
May  the  right  leg  was  flexed  at  the  hip.  The  haematoma  in  the  right  iliac 
fossa  became  very  tense.  Pulsation  could  not  be  perceived  either  in  the 
aneurism al  sac  or  in  the  extravasation,  and  was  greatlv  diminished  in  force 
in  the  femoral  artery.  It  was  thought  that  the  circulation  in  the  aneurism 
must  have  ceased,  and  that  the  perianeurismal  haematoma  had  no  direct 
communication  with  the  blood  stream.  But  as  the  patient  remained  unre- 
lieved of  his  pain,  it  seemed  indicated  to  open  and  empty  the  sac  in  the 
manner  which  had  recently  been  recommended  by  Mikulicz." 

So  37  days  after  the  first  operation,  on  the  23d  of  May,  1899,  a  second 
was  undertaken.  The  incision  led  into  great  masses  of  coagulated  blood, 
which  were  extruded  under  great  pressure.  The  tumor  collapsed.  As  the 
cavity  was  almost  completely  emptied  there  took  place,  suddenly,  a  profuse 

*  Zur  operativen  Behandlungen  der  Aneurysmen.  Beitrage  zur  klin.  Chirurgie, 
Band  xxiv.  5,  418.    Hoffman. 


COMMON  ILIAC  AETEEY  357 

arterial  haemorrhage.  This  could,  for  a  time  only,  be  arrested  by  compres- 
sion and  tamponade.  To  search  for  the  bleeding  point  in  the  enormous  hole 
partly  filled  with  coagula  seemed  unwise.  Therefore,  transperitonaeally, 
through  a  mid-line  incision,  the  aorta  was  ligated,  at  first  over  a  little  bunch 
of  gauze.  Thereupon  the  bleeding  ceased.  Then,  through  a  long  cut  in  the 
right  flank,  Prof.  Korte  completely  evacuated  the  contents  of  the  enormous 
cavity.  At  the  right  edge  of  the  true  pelvis,  in  the  neighborhood  of  the 
internal  iliac,  he  encountered  a  bright,  but  trivial  haemorrhage  which  was 
controlled  by  pressure.  The  aortic  ligature  was  now  definitely  tied  and  the 
wounds  sutured.  The  patient  was  greatly  collapsed,  and  died  one  hour  after 
the  operation. 

At  the  autopsy  it  was  determined  that  the  patient  suffered  from  wide- 
spread disease  of  the  arterial  system,  which  had  led  to  the  formation  of 
aneurism  of  the  aorta,  right  and  external  iliac,  right  femoral  and  right  pro- 
funda femoris  arteries. 

19.  (Group  II.)  Martin,  A.  A.  Ligation  of  the  left  common  iliac  artery 
for  aneurism  from  a  bullet  wound  of  the  external  iliac.  Recovery.  Cure  of 
aneurism.  By  Arthur  A.  Martin,  M.  B.,  Ch.  B.  Edin.,  Civil  Surgeon,  South 
African  Field  Force.  ( Communicated  bv  the  Director-General,  Army  Medi- 
cal Service.   Brit.  Med.  Jour.,  Jan.  17/1903.) 

Private  soldier,  aet.  31.  Admitted,  November  18,  1901,  to  General  Hos- 
pital, Howick,  Natal. 

Examination. — Healed  bullet  wound  of  left  groin.  The  wound  of  entrance 
was  about  three  fingers'  breadth  above  Poupart's  ligament  and  internal  to 
the  external  iliac  artery.  The  wound  of  exit  was  below  the  crest  of  the  ilium 
of  the  same  side.  The  bullet  had  crossed  the  external  iliac,  "  wounded  the 
artery  high  up,"  and  pierced  the  iliac  bone.  A  marked  bulging,  expansive 
pulsation  and  bruit  were  noted,  and  the  diagnosis  of  aneurism  made. 

November  23d. — The  aneurism,  which  had  greatly  increased  in  size,  now 
extended  a  finger's  breadth  below  the  umbilicus  and  to  the  middle  line.  The 
patient's  temperature  was  101.6°  F. 

Operation. — The  incision  began  one  and  one-half  inches  above  the  center 
of  Poupart's  ligament,  and  extended  to  one  inch  above  and  internal  to  the 
anterior  superior  spine.  The  fascia  and  muscles  were  cut  through  in  the 
line  of  the  skin  incision  which,  being  found  too  short,  was  prolonged  up- 
wards in  a  curve  with  the  convexity  downwards  and  outwards.  Peritonaeum 
incised.  The  external  iliac  artery  could  not  be  defined.  The  common  and 
internal  iliac  arteries  seemed  to  enter  the  upper  part  of  the  aneurismal  mass. 
The  former  artery,  twice  ligated,  was  divided  between  the  ligatures  of  double 
silk.  Wound  undrained  and  sealed.  The  limb  was  enveloped  in  cotton  wool 
and  firmly  bandaged. 

November  25th. — Patient  said  he  could  not  "  feel "  his  left  leg. 

November  26th. — Vomited  several  times.  No  abdominal  distension.  The 
left  leg  was  much  colder  than  the  right.  "  Eoots  of  the  toes  very  oedema - 
tous."  Limb  blanched.  Skin  below  the  knee  quite  anaesthetic.  No  pulsation 
in  tibial  or  popliteal. 

November  27th. — Large  watery  blebs  on  leg  and  foot.  Anaesthesia  below 
the  knee  unchanged.  No-pain  in  groin  since  operation. 


358  LIGATION  OF 

November  30th. — Patient  could  "feel"  his  leg,  which  seemed  "heavy 
as  lead."  Temperature  of  left  leg  nearly  equal  to  that  of  the  other  side. 
Blisters  and  oedema  vanished. 

December  22d. — The  mass  in  iliac  region  was  smaller,  hard  and  without 
pulsation. 

January  — ,  1902. — Patient  could  easily  flex,  extend  and  rotate  leg,  but 
was  unable  to  "  lift  it  vertically  "  when  lying  on  the  back. 

February  3d. — Could  walk  about  slowly.  The  mass  in  the  left  iliac  fossa 
reduced  to  size  of  a  goose  egg. 

The  author  makes  the  important  comment  that  "  the  deep  epigastric  and 
deep  circumflex  iliac  arteries  fortunately  came  off  below  the  aneurism." 

20.  (Group  II.)  Maynard,  P.  P.  Ligation  of  the  right  common  iliac 
artery  for  diffused  iliac  aneurism.  Death.  (The  Indian  Med.  Gazette,  Cal- 
cutta, 1903,  p.  253.  F.  P.  Maynard,  F.  K.  C.  S.  (Eng.),  Major  I.  M.  S., 
Surgeon  Superintendent,  Mayo  Native  Hospital,  Calcutta.) 

Male,  native,  aet.  32.  Admitted,  April  17,  1903,  to  the  Mayo  Hospital. 

History. — Patient  had  never  had  any  venereal  disease.  Four  or  five 
months  before  admission  he  noticed  a  pulsating  tumor  in  the  right  groin. 
Growing  gradually  larger,  it  did  not  pain  him  severely  until  a  month  later, 
when  it  began  to  increase  rapidly  in  size. 

April  7th,  after  a  stool,  he  felt  "  as  if  a  gust  of  wind  ran  from  his  abdo- 
men into  the  scrotum."  Thereupon  he  noticed  that  the  penis  and  scrotum 
had  swelled,  and  experienced  pain  in  these  parts. 

Status. — A  tall,  thin  man  with  anxious  expression.  Pulse  99 ;  respiration 
normal;  temperature  100.8°  F. ;  cough,  but  no  physical  signs  of  tuberculosis. 
Urine  normal.  A  large,  tense,  rounded,  pulsating  tumor,  occupying  the  right 
inguinal  region,  extended  from  about  2  inches  below  navel  to  3  or  4  inches 
below  Poupart's  ligament.  This  swelling  was  continuous  with  the  swollen 
scrotum,  which  also  had  expansile  pulsation  synchronous  with  the  heart's 
systole.  A  loud  systolic  bruit,  heard  over  the  entire  area  of  pulsation,  was 
loudest  at  the  upper  and  outer  part  of  the  tumefaction.  The  penis  was  very 
oedematous.  The  abdominal  wall,  as  high  as  the  left  nipple,  and  the  upper 
fourth  of  the  left  thigh  showed  a  brownish  discoloration  from  subcutaneous 
haemorrhage.  Feeble  pulsation  could  be  felt  in  the  right  femoral  and 
tibial  arteries. 

April  20th. — A  portion  of  the  scrotum  had  become  black  and  anaesthetic. 

Operation. — An  abdominal  incision,  in  the  mid-line,  was  carried  below 
into  the  area  of  subcutaneous  haemorrhage,  where  troublesome  bleeding  was 
encountered.  The  intestines  gave  great  annoyance,  and  had  to  be  brought 
out  of  the  belly,  where  they  were  wrapped  in  warm,  sterile  towels.  The 
operator  regretted  that  he  had  not  arranged  for  the  Trendelenburg  position. 
Three  strands  of  silk  were  passed  under  the  common  iliac  artery  without 
difficulty.  These  were  not  drawn  so  tightly  in  tying  as  to  cut  through  the 
inner  arterial  coats.   Pulsation  in  the  swelling  ceased  on  tying  the  ligature. 

April  21st. — Patient  developed  bronchitis  and  vomited  occasionally. 

April  22d. — Abdomen  tympanitic.  The  aneurism  was  hard,  the  scrotum 
and  toes  warm.  Bronchitis  better. 

April  21fth. — Had  several  stools  (diarrhoea),  accompanied  by  the  passage 
of  some  gas.  The  heat  (106°  F.  in  the  shade)  was  very  oppressive. 


COMMON  ILIAC  ARTERY  359 

April  26th. — The  diarrhoea  and  vomiting  persisted.  The  aneurism  had 
decreased  in  size.   The  wound  seemed  to  be  healed. 

On  the  evening  of  the  27th,  patient  had  several  loose  stools,  and  died 
quite  suddenly.   A  post-mortem  examination  was  not  permitted. 

The  circulation  of  the  extremity  had  not  been  manifestly  affected  by  the 
operation. 

21.  (Group  I.)  Czerny,  V.  Ligation  of  the  left  common  iliac  for  the 
arrest  of  haemorrhage  from  a  small  branch  of  this  artery  torn  from  the 
parent-stem  in  the  course  of  operation  for  the  removal  of  tuberculous  glands. 
(Dreist.  Deutsche  Zeitschrift  f.  Chirurgie,  1904,  p.  10.) 

Male,  aet.  28.  Admitted  to  the  surgical  clinic  for  pelvic  tumor.  Had  four 
years  previously  been  admitted  to  the  hospital  for  traumatic  haemarthrosis 
genu  and  haematoma  femoris. 

Examination. — The  tumor  in  the  pelvis,  although  quite  hard,  gave  evi- 
dence of  fluctuation.  It  was  movable  on  the  ilium.  Per  rectum  there  was 
felt,  in  the  neighborhood  of  the  symphysis  sacroiliaca  dextra,  a  resistant 
body  lying  upon  the  bone,  which  it  was  thought  might  be  an  exudate. 

Diagnosis. — Lymph  glands,  suppurating,  and  probably  tuberculous. 

Operation,  February  26,  1897. —  (Professor  Czerny.)  Nodular  masses 
composed  of  glands  were,  without  much  difficulty,  removed  from  along  the 
inner  edge  of  the  iliopsoas  muscle,  but  not  so  easily  from  the  external  iliac 
artery,  which  for  5  cm.  was  imbedded  in  them,  mesially.  In  separating  the 
packet  of  glands  from  the  vessels,  a  small  branch  of  the  common  iliac  artery 
was  torn  off  so  near  its  parent  stem  that  ligation  of  the  latter,  being  consid- 
ered imperative,  was  done.  Three  ligatures  of  thick  catgut  were  employed, 
but  not  drawn  so  tight  as  to  cut  through  the  arterial  wall.  Other  conglom- 
erations were  found,  i.  e.,  in  the  pelvis  and  praesacral  area.  The  removal  of 
the  diseased  glands  was  continued  without  other  untoward  incident.  It  was 
constated  that  the  deep  epigastric  vessels  were  not  injured.  The  wound  was 
tamponed. 

During  the  first  two  days  the  left  extremity  was  somewhat  cold.  There 
was  no  disturbance  of  sensation  following  the  operation,  nor  was  there  any 
pain. 

On  and  after  the  10th  of  March,  there  were  irregular  elevations  of  tem- 
perature, at  first  associated  with  frontal  headaches.  Pulmonic  rales  were 
detected;  then  followed  night  sweats  and  slight  expectoration,  and  on  the 
30th  of  July,  1897,  the  patient  died  of  acute  miliary  tuberculosis. 

At  autopsy  a  double  ligature  was  found  on  the  common  iliac  artery,  with 
associated  thrombus  extending  to  the  bifurcation  of  the  aorta.  The  col- 
lateral circulation  seemed  to  have  been  established  largely  by  means  of 
anastomosis  between  the  internal  iliac  arteries  of  the  two  sides  without  the 
presence  of  any  large  communicating  branch. 

22.  Kuster,  Ernst.  Ligation  of  the  left  common  iliac  and  other  arteries 
for  elephantiasis  of  the  lower  extremities.  Result  negative.  (Karl  Dreist, 
Deutsche  Zeitschrift  fur  Chirurgie,  1904,  lxxi,  32.) 

Female,  aet.  17.  Admitted,  December  3,  1897,  to  the  surgical  clinic  of 
the  University  of  Marburg. 


5  LIGATION  OF 

Anamnesis. — Parents  and  fire  brothers  and  sisters  alive  and  weD.    Two 

7r.ir;  ir:.  ; .:-:  :.:.v:  „.:.--  -::"-  ::"-::.•:..  ::i  ^:-  '.-:irir  ?-:llri..  \i'. 
without  causing  any  discomfort.  The  swelling  has  steadily  increased. 
11-z.r.riL:: :-     ::?.:  :~  :  .:  1  •  :"_  ;  -;.:  .•- .:  "r..--  ;..~:.;  f  :r:'_  :::tj:^:. 

Status  on  Admission. — Body  well  nourished.  Skm  rather  pale.  Findings 
in  thorax  and  abdomen  normal.  Pulse  slow  and  somewhat  irregular.  Urine 

n.nii."..    Z::ji  '.:~-z  -~~- :-»  !;.:::  mi  i'z.i.z-'-i:~i.    ~'—ZZi  •;-  _zz.  :::  :::- 

:~r  jtTt'  :-t.  T".Lt  It-i:  :ilr  =  :  :~.  TIt  :~:  ;.Tt  — — -:>ei.  Tir  m.i.  ir^- 
ir^rmill-  *-:lii:  ::.;  -r^ir-  irr-e  mi  ::.t7t  ;.:t  iiliTri.  Zz.-:-  zz-  :-'.::::r> 
:-ct-  ::.  :_t  ."It?:,  .t..  im.  rrfim  ii:  iii:. 

Treatment. — Elevation  of  the  limbs  and  compression. 

December  8th. — The  swelling  of  the  thighs  is  diminished  by  6  cm. ;  of  the 
legs  by  5  cm. 

December  20th,  a.  m. — Allowed  to  stand  for  the  first  time;  p.  m.,  the 
legs  are  again  as  large  as  ever. 

January  7th,  1898. — Ligation  of  the  right  femoral  artery  below  Pouparfs 
ligament.  The  subcutaneous  fat  was  so  thick  that  the  finding  of  the  artery 

~li     ~t7~      '-—---        ~Zr    '  ■  —  '■      "'  -■-;-,*--     TilrT     iZZiZ    '.—  -.      '.Z-.ZZ'.i.Z.. 

January  18th. — Decided  decrease  in  the  circumference  of  the  right  ex- 
tremity. The  skin  has  become  softer. 

January  28th — Ligation  of  the  left  femoral  artery  below  Pouparfs 


February  10th. — Seduction  in  siae  of  the  left  limb. 

February  Both. — Patient  being  permitted  to  stand,  the  swelling  promptly 

n::-^r;. 
March  8th — Extraperitonaeal  ligation  of  the  right  external  iliac.   The 

-t^t!  ~i.«  --- ;-  -zzzL.    ~  izzzy.-Z-i.z-. .    !'•::;  rl-i. 
J.-.  " ■'.  J_::  — Zzr.ziZzzz-.Lri  -.mil  zz.  y.z-. 
April  90th — Patient  allowed  to  walk.    No  swelling  observable  in  the 


May  12th— Swelling  as  great  as  c 

June  23d. — Extraperitonaeal  ligation  of  the  left  common  iliac.    Limb 

:■:■:'.-  .  ;-.irI?  :-::.::; 
June  27th — Temperature  of  both  extremities  the  same. 

.-: '_;'-..•:  -.:'.— ?.~il.   ::  :':..   ::r:i:;:r?  zz.zir.-.. 

23.  (Group  L)  Trendelenburg,  Friedrich.  Ligation  of  the  left  common 
artery  for  aneurisma  dissecans  of  this  vessel.  Death  (Communicated  by 
Dreist,  L  c,  p.  12.) 

Male,  aet  60.  Admitted,  October  4,  1898,  to  Professor  Trendelenburg's 
..;- : :  :n  Z- :~  z  _~ 

Examination, — General  condition  wretched.  Patient  had  suffered  from 
pain  in  the  abdomen  for  a  year,  and  on  the  day  of  admission  had  done  a 
full  day?  work,  although  repeatedly  complaining  to  his  fellow  laborers  of 
drawing  pains.  Suddenly,  about  6  p.  nu,  very  severe  pains  set  in,  and  he 
rapidly  became  pale  and  weak. 

Status  on  Admission. — Patient  very  pale  and  in  great  pain.  There  was 
eructation  but  no  vomiting.  The  abdomen  was  greatly  distended.  Liver 
dullness  normal  On  the  left  side  of  the  abdomen  was  palpated  a  tense, 
elongated  tumor  of  the  sue  of  one's  arm,  which,  in  its  course,  corresponded 


COMMOX  ILIAC  AETEEY  361 

to  the  situation  of  the  descending  colon.  The  percussion  note,  nowhere 
metallic,  was  dull  over  the  tumor.  Nevertheless  it  was  thought  that  perhaps 
there  was  volvulus  of  the  sigmoid  flexure,  and  an  exploratory  laparotomy 
was  promptly  made. 

On  incision  of  the  abdominal  wall,  a  large  amount  of  blood  was  observed 
extravasated  in  the  praeperitonaeal  space.  The  hand  in  the  abdominal  cavity 
ascertained  that  the  tumor  was  retroperitonaeal. 

An  incision  was  made  into  this  haematoma.  On  removal  of  coagula  there 
was.  at  first,  no  fresh  bleeding,  and  there  was  found  at  the  bottom  of  the 
large  cavity  a  pulsating  aneurism  with  rounded  surface,  which  led  towards 
the  aorta,  but  was  situated  between  the  lumbar  vertebrae  and  the  psoas 
muscle.  Suddenly  there  spurted  from  the  aneurism  a  thick  stream  of  blood! 
Compression  was  made:  but  under  the  compressing  finger  the  rent  in  the 
aneurism  became  greater,  whereupon  the  blood  welled  forth  in  a  great  flood. 

The  aneurism  was  laid  freely  open,  and  a  ligature  applied  to  its  root,  near 
the  aorta.  Haemorrhage  from  the  distal  side  was  controlled  by  a  clamp  and 
by  tying  off  the  rent  with  a  strip  of  gauze.  Skin  suture.  Infusion  of  900  c.  c. 
salt  solution.  Patient  awoke  from  the  narcosis,  evinced  great  restlessness, 
and  died  in  three  hours. 

Autopsy. — Dissecting  aneurism  of  the  right  common  iliac.  Fusiform 
aneurism  of  the  left  common  iliac,  the  size  of  a  hen's  egg.  immediately  below 
the  aortic  bifurcation.  A  tear  of  the  intima,  in  the  middle  of  the  aneurism, 
transverse  to  its  long  axis.  Diffuse  arteriosclerosis  of  the  entire  aorta. 
Arteriosclerosis  with  calcareous  infiltration  of  the  right  coronary  artery  of 
the  heart  and  of  both  iliacs. 

2-4.  (Group  II.)  Christel.  Ligation  of  the  left  common  iliac  artery  for 
spurious  aneurism  of  the  femoral.  Recovery.  Gangrene.  (Dreist.  J.  c, 
p.  6.) 

Male,  aet.  28.  Blacksmith.  On  January  28,  1901,  a  glowing  splinter  of 
iron  penetrated  the  left  thigh,  and  thereupon  a  strong  pulsating  stream  of 
blood  spurted  from  the  wound.  Patient  controlled  the  bleeding  with  his 
thumb  until  the  arrival  of  a  physician,  who  applied  a  compressing  bandage. 
Eight  days  after  the  injury,  patient  was  allowed  to  go  about.  Severe  pains, 
with  tension  in  Scarpa's  triangle,  compelled  him  to  take  to  his  bed  again. 
The  swelling  increased  and  the  pains  became  unbearable. 

March  1,  1901. — Admitted  to  Eombacher  Spital.  Metz. 

Status,  March  5th. — Patient  was  greatly  emaciated  and  anaemic. 
Eesembled  a  consumptive  in  the  last  stages  of  the  disease.  Pulse,  thready 
(126+ ).  Eectal  temperature  36.7°.  Left  thigh  enormously  swollen.  A 
small  scar,  10  cm.  below  anterior  superior  spine,  along  the  inner  edge  of 
the  sartorius.  The  oedema  extended  to  the  level  of  the  navel.  Skin  of  the 
thigh  livid,  and  its  veins  distended  in  the  region  of  the  tumor.  Auscultation 
over  it  negative.   Pulsation  in  the  posterior  tibial  artery  was  distinct. 

Diagnosis. — Spurious  aneurism,  with  beginning  suppuration  of  the  fe- 
moral or  a  branch  of  this  artery. 

Operation,  March  6th. — Incision  over  the  greatest  convexity  of  the  tumor 
led  into  a  large  hole,  between  the  extensor  and  adductor  muscles,  lined  with 
coagula.  The  femoral  vein  was  thick  as  a  finger,  tensely  full  and  non- 
pulsating.    Blood  welled  up  from  the  depths  of  the  wound.    Attempts  to 


362  LIGATION  OF 

remove  the  clots  from  the  infiltrated  and  friable  tissues  caused  such  very- 
profuse  bleeding  that  they  were  abandoned.  Preparations  made  for  the  liga- 
tion of  the  external  iliac.  An  incision  parallel  to  Poupart's  ligament  laid 
bare  this  artery,  which  was  then  ligated  below  the  origin  of  the  deep  epigas- 
tric, because  the  latter  vessel  was  given  off  at  an  abnormally  high  point. 
During  the  manipulations,  the  epigastric  was  torn  off  and  ligated.  The 
external  iliac  was  again  ligated  above  the  origin  of  the  epigastric. 

Then  the  wound  of  the  thigh,  which  had  been  tamponed  with  gauze,  was 
reinvestigated.  There  was  still  bleeding  from  several  unrecognizable  sources. 
The  patient  was  so  collapsed  that  a  further  loss  of  blood  could  not  be  sus- 
tained. Hence  it  was  determined  to  ligate  the  common  iliac.  This  was  done 
extraperitonaeally.  The  bleeding  from  the  wound  of  the  thigh  was  thereby 
arrested.  The  femoral  artery  was  again  searched  for  in  this  wound  but  not 
found.   Both  wounds  were  tamponed  with  iodoform-gauze. 

"  After  a  time,"  the  left  leg  became  cold  and  insensible.  A  livid  dis- 
coloration of  the  foot  appeared.  The  gangrene  extended  gradually.  A  line 
of  demarcation  formed  about  the  junction  of  the  middle  and  upper  thirds 
of  the  leg.  The  patient  became  soporific.  Pulse  124;  temperature  103.5°  P. 
Notwithstanding  the  desperate  condition  of  the  patient,  Dr.  Christel  ampu- 
tated "  the  same  day."  Gradual  recovery  took  place,  and  October  6,  1901, 
the  patient  was  supplied  with  a  prothesis. 

In  March,  1903,  Dr.  Dreist  again  saw  the  patient,  who  had  entirely 
regained  his  health. 

Whether  it  was  the  femoral,  or  a  branch  of  this  artery,  which  had  been 
injured  by  the  iron  splinter,  was  never  determined.  What  vessels  besides 
those  mentioned  may  have  been  ligated  or  injured  is  not  known.  It  is  at 
least  certain  that  the  gangrene  is  not  to  be  attributed  solely  to  the  ligation 
of  the  common  iliac.  Inasmuch  as  the  external  iliac  was  ligated  above  and 
below  the  torn  off  epigastric  artery,  it  is  probable  that  the  circumflex  iliac 
also  had  its  origin  between  these  ligatures.  The  profunda  femoris  with  its 
circumflex  branches  may  have  been  injured  either  by  the  iron  splinter  or  in 
the  attempts  to  check  the  haemorrhage  from  the  wound  of  the  thigh. 

25.  (Group  I.)  Clark,  Henry  E.,  C.  M.  G.  Senior  Surgeon,  Glasgow 
Royal  Infirmary.  Ligation  of  the  left  profunda  femoral  and  common  iliac 
arteries  for  wound  of  the  profunda  artery  and  vein.  Recovery.  (Brit.  Med. 
Jour.,  Oct.  7,  1905,  p.  850.) 

This  case  is  so  briefly  and  picturesquely  reported  that  I  retell  the  story 
in  the  words  of  the  operator. 

"H.  B.  Porter,  aged  26,  was  admitted  into  Ward  25,  Glasgow  Royal 
Infirmary,  on  April  25,  1899,  suffering  from  a  small  punctured  wound  at 
the  inner  side  of  the  left  thigh,  at  the  junction  of  the  upper  and  middle  third. 

"  His  story  was  that  he  and  another  man  were  having  a  fight,  when  the 
latter  whipped  out  a  penknife  and  came  at  him.  In  trying  to  escape  from 
the  assault,  he  fell,  and  his  assailant  fell  on  top  of  him,  and  the  blade  of  the 
knife  ran  into  the  thigh,  right  up  to  the  hilt.  The  wound  bled  very  freely, 
but  a  doctor  was  soon  in  attendance,  who  put  on  a  pad  and  a  bandage.  When 
he  reached  the  hospital  the  bleeding  had  ceased,  and  on  the  following  morn- 
ing, when  I  saw  him  at  the  usual  visit  hour,  the  wound  was  so  well  plugged 


COMMON  ILIAC  ARTERY  363 

with  clot  that  I  thought  it  unwise  to  disturb  it.  All  went  well  till  May  12th, 
when  the  wound  was  found  to  be  bleeding  freely,  suppuration  having  taken 
place,  and  the  clot  having  consequently  broken  down.  I  thoroughly  opened 
up  the  wound,  and  exposed  the  main  trunk  of  the  profunda  f emoris  artery, 
which  had  been  incompletely  divided;  this  was  double  ligatured  and  cut 
across.  The  vein  was  also  found  to  be  injured,  and  was  more  difficult  to 
secure  effectively  than  the  artery. 

"  Three  days  afterwards  (on  May  15th),  when  the  patient  was  using  the 
bedpan,  he  became  suddenly  blanched  and  pulseless,  and  the  dressings 
became  saturated  with  arterial  blood.  I  was  fortunately  on  the  spot  at  the 
time,  and  at  once  took  him  to  the  operating  theater,  where  I  ligatured  the 
common  femoral  artery  just  at  its  emergence  from  beneath  Poupart's  liga- 
ment. This  arrested  the  bleeding,  and  he  very  rapidly  recovered  from  the 
loss  of  blood,  until  five  days  later  (May  20th),  when  a  still  more  serious 
haemorrhage  took  place.  On  this  occasion,  also,  I  happened  to  be  in  the 
infirmary  and  at  once  applied  an  elastic  bandage  round  the  pelvis  and  hip, 
but  as  this  did  not  control  the  bleeding,  it  was  decided  to  ligature  the  com- 
mon iliac  artery.  This  was  done  by  Sir  Philip  Crampton's  method,  as 
described  by  him  in  the  Medico-Chirurgical  Transactions,  Vol.  xvi,  p.  161, 
as  far  back  as  1828.  The  incision  commenced  at  the  anterior  extremity  of 
the  last  rib,  proceeded  downwards  directly  to  the  ilium,  then  followed  the 
line  of  the  crest,  but  keeping  a  little  within  its  inner  margin,  until  it  termi- 
nated at  the  anterior  superior  spine.  The  abdominal  muscles  were  divided 
in  the  full  extent  of  this  incision  till  the  peritonaeum  was  reached,  when  that 
structure  with  the  contained  intestines  was  lifted  up  off  the  iliac  and  the 
lumbar  fasciae.  The  ureter  was  raised  with  the  peritonaeum.  An  excellent 
view  of  the  external  and  common  iliac  arteries  was  obtained,  and  the  bleed- 
ing was  slight  and  easily  controlled.  By  means  of  a  helix-curve  aneurism 
needle  the  common  iliac  artery  was  freed  from  a  small  amount  of  fat,  and 
a  strong  chromic  gut  ligature  passed  and  securely  tied.  The  large  wound 
was  for  the  most  part  stitched  up  in  layers,  but  the  part  in  the  loin  was 
packed  with  iodoform  gauze.  The  patient  stood  the  operation  well,  and  made 
up  rapidly  for  the  loss  of  blood.  Unfortunately,  the  wound  suppurated,  but 
this  was  not  wonderful,  considering  that  there  had  been  all  along  an  infection 
of  the  oringal  wound,  probably  from  septic  material  carried  in  by  the  knife. 
This,  however,  materially  delayed  the  healing,  and  it  was  not  till  August  11th 
that  he  was  dismissed  to  the  Convalescent  Home. 

"  After  leaving  the  wards  he  was  only  seen  once  by  me,  as  he  found  it 
impossible  to  come  to  the  infirmary  on  week-days.  He  was  seen  by  one  of  my 
dressers,  and  also  by  my  staff -nurse  fully  six  months  after  leaving  us,  and 
was  then  in  full  employment  as  an  outside  porter  at  the  Glasgow  Central 
Railway  Station.  I  understood  his  work  to  consist  mainly  in  taking  commer- 
cial travellers'  large  sample  boxes  on  a  hand-barrow  about  the  town — 
a  sufficiently  trying  and  laborious  occupation.  It  is  not  too  much,  I  think, 
to  claim  this  not  only  as  a  '  recovery '  but  as  a  perfect  cure." 

26.  (Group  II.)  Cranwell,  D.  J.  Ligation  of  the  right  common  iliac 
for  aneurism  of  the  external  iliac  and  femoral  arteries.  Gangrene.  Death. 
(Tratamiento  de  los  anuerismos  de  la  iliaca  externa.  Por  el  doctor  Daniel  J. 


364  LIGATION  OF 

Cranwell,  Profesor  suplente  de  clinica  quirurgica.  Kevista  de  la  Sociedad 
Medica  Argentina,  1906,  xiv,  p.  388.) 

Male,  aet.  48.  Blenorrhagia  at  the  age  of  16  years.  Alcoholic.  Thirty 
years  ago,  after  a  walk,  he  suffered  with  cramps  in  the  right  leg  which  made 
him  halt.  Later,  a  small  tumor  appeared  in  the  right  groin  which  for  15 
years  grew  slowly,  and  then  more  rapidly,  until  August,  1903,  when  he 
received  a  blow  in  the  affected  regions.  Ever  since  then  the  growth  has 
increased  and  the  leg  has  been  swelling.  For  the  past  30  years  he  has  had 
intermittent  pains  in  the  lower  part  of  the  thigh  at  the  base  of  Scarpa's 
triangle  and  in  the  knee,  which  were  greater  at  night  and  with  exercise. 

Status. — A  very  lean  individual  in  bad  general  condition.  The  thigh  is 
flexed,  abducted  arid  rotated  outwards.  Occupying  the  base  of  Scarpa's 
triangle  and  the  right  iliac  fossa,  there  is  a  tumor  as  large  as  the  head  of 
a  child.  Poupart's  ligament  indents  the  mass,  the  lower  part  of  which,  as 
big  as  an  orange,  is  somewhat  drawn  out  in  the  course  of  the  femoral 
vessels.  The  skin  over  it  is  normal,  and  not  adherent  to  the  underlying 
tumor.  The  swelling  is  soft  and  expands  with  pulsation.  The  thigh  and  leg 
are  oedematous.  Patient  suffers  excruciating  pain  in  the  hip  and  inner  part 
of  the  thigh.  Motions  of  the  joint  are  greatly  restricted  because  of  the  pain. 
He  has  numerous  subcutaneous  lipomata  and  general  arteriosclerosis. 

Diagnosis. — Aneurism  of  the  external  iliac  and  femoral  arteries. 

Operation,  February  28, 1904  (  ?)• — Trendelenburg  position,  median  inci- 
sion. Transperitonaeal  ligation  of  the  right  common  iliac  just  below  the 
bifurcation  of  the  aorta.  Immediate  cessation  of  pulsation  in  the  aneurism. 

March  1st. — The  leg  was  livid  and  without  sensation  from  the  calf  to 
the  toes. 

March  2d. — Gangrene  of  the  leg.  Amputation  about  the  middle  of  the 
thigh. 

The  patient's  general  condition  improved  for  a  time,  but  the  wound 
showed  no  tendency  to  heal.  The  arteries  were  rigid  and  pulsated  forcefully. 

April  4th. — Sacral  decubitus.  Death. 

27.  (Group  II.)  Gillette,  Wm.  D.  Ligation  of  the  left  common  iliac 
artery  for  the  cure  of  ischiadic  aneurism.  The  internal  and  external  iliacs 
were  also  ligated  and  the  sac  dissected  out  and  tied  off.  Gangrene.  (Annals 
of  Surgery,  1908,  xxxviii,  22.) 

Patient,  male,  aet.  56.  Aneurism  of  left  sciatic  artery  attributed  to  severe 
fall  about  17  months  prior  to  operation.  The  aneurism  extended  so  high 
towards  the  pelvis  that  ligation  of  the  afferent  artery  was  not  attempted. 
So  (April  22,  1905)  the  left  internal  iliac  was  tied  near  its  origin.  The 
patient  recovered  uneventfully.  Pulsation  ceased  in  the  aneurism,  which 
rapidly  diminished  in  size.  For  seven  months  a  cure  was  believed  to  have 
been  effected.  Then  pulsation  reappeared  in  a  small  tumor  at  the  original 
site  of  the  aneurism.  Patient  did  not  consent  to  further  operation  until 
three  months  later,  when  the  aneurism  had  greatly  enlarged,  although  not 
to  its  former  dimensions,  April  18,  1906.  Dr.  Gillette  exposed  the  pulsating 
tumor  in  the  buttock,  hoping  to  ligate  the  artery  leading  to  it,  or  to  perform 
the  Matas  operation.  Neither  procedure  was  feasible.  The  abdomen  was 
then  opened  and,  as  compression  of  the  external  iliac  artery  seemed  to 


COMMON  ILIAC  ARTERY  365 

obliterate  the  pulsation  in  the  aneurism,  this  artery  was  ligated.  But  on 
reexamination  of  the  tumor,  it  was  found  that  the  pulsation  had  not  been 
affected  in  the  least.  So  the  common  iliac  artery  was  tied  close  to  the  aortic 
bifurcation.  Then,  through  the  incision  in  the  buttock,  the  sac  of  the  aneu- 
rism was  freely  opened  and  tied  off  at  the  highest  possible  point. 

On  the  third  day  signs  of  gangrene  of  the  leg  appeared,  and  on  the  sixth 
day  amputation  was  made  at  the  juncture  of  the  upper  and  middle  thirds 
of  the  leg.  Sloughing  of  the  flaps  necessitated  amputation  of  the  thigh. 
Recovery. 

28.  (Group  II.)  Halsted.  TV.  S.  Occlusion  of  the  left  common  iliac  with 
an  aluminum  band  for  aneurism  of  the  external  iliac  and  femoral  arteries. 
Recovery.  Aneurism  cured.    (Case  hitherto  unreported.) 

M.  R.,  German,  aet.  44,  was  admitted  to  The  Johns  Hopkins  Hospital 
December  28,  1908,  complaining  of  tumefaction  and  pain  in  the  left  groin. 

Story. — Has  always  enjoyed  good  health.  Believes  that  he  had  malaria 
at  some  time.  Contracted  specific  urethritis  at  the  age  of  22,  and  at  the 
same  time  a  venereal  sore  which  was  accompanied  by  enlarged  inguinal 
glands.  Has  had  no  secondary  manifestations  of  lues.  Drinks  two  bottles 
of  beer  daily,  is  otherwise  temperate.  About  two  and  one-fourth  years  ago, 
patient  in  falling  was  struck  in  the  left  groin  with  the  iron-bound  edge  of 
a  barrel.  He  suffered  no  immediate  inconvenience  from  the  trauma,  but 
three  months  later  felt  a  "  drawing  "  pain  in  the  left  groin  and  leg.  This 
pain  was  especially  severe  in  the  calf,  and  prevented  him  from  doing  much 
walking. 

Four  or  five  months  after  the  injury,  the  leg  began  to  swell.  About 
September,  1908,  the  pain  ceased,  in  the  leg,  but  increased  in  the  groin, 
where  it  assumed  a  "  burning  character."  More  than  one  and  a  half  years 
ago  a  lump  in  the  groin  was  noticed.  This  has  been  *  getting  larger  "  and 
tender,  and  patient  has  observed  that  it  pulsates.  The  burning  pains  in  the 
swelling  are  intensified  by  walking. 

Status  Praesens. — Patient  is  well  nourished  and  seems  to  be  robust. 
Examination  of  the  eyes.  ears,  nose,  mouth,  chest  and  rectum  reveals  noth- 
ing abnormal.  Radial  and  temporal  arteries  slightly  hard  and  tortuous. 
Pulse  90.  Cicatrices  in  both  groins.  In  the  left  groin  is  a  large,  very  tense 
pulsating  mass,  over  which  the  skin,  oedematous,  reddish  and  glistening,  is 
tightly  stretched.  The  swelling  extends  laterally  to  the  anterior  superior 
spine  of  the  ilium,  mesially  to  the  mid-line,  upwards  to  within  8  cm.  of  the 
umbilicus  and  downwards  to  a  point  12  cm.  below  Poupart's  ligament.  It 
measures  26  cm.  in  the  transverse,  and  20  cm.  in  the  longitudinal  diameter. 
It  has  forced  the  external  ring  downwards  and  the  canal  forwards,  so  that 
the  finger  cannot  enter  the  former.  The  mass  expands  in  all  directions  with 
the  pulsation,  the  heave  from  which  is  so  strong  that  motion  is  communi- 
cated to  the  penis  and  scrotum  with  each  heart-beat.  A  loud  systolic  bruit 
is  to  be  heard,  and  a  thrill  to  be  felt,  over  the  tumor. 

The  right  foot  is  colder  than  the  left.  Pulsation  in  the  popliteal,  posterior 
tibial  and  dorsalis  pedis  arteries  is  not  perceivable.  The  left  thigh  at  20  cm. 
above  the  patella  measures  51.5  cm.,  the  right  47  cm.;  the  left  calf  35  cm., 
the  right  30.5  cm.    The  veins  and  venules  of  the  left  limb  are  enlarged. 


366  LIGATION  OF 

Sensation  and  motility  are  normal.  White  blood  corpuscles  8400.  Haemo- 
globin 81  per  cent  (Sahli). 

There  seems  to  be  a  delay  of  pulsation  in  the  tumor  of  three  hundredths 
of  a  second.  The  lower  edge  of  the  swelling  is  abrupt,  and  a  little  over- 
hanging. The  patient  rests  most  comfortably  with  the  thigh  slightly  flexed 
and  abducted.  There  is  an  apparent  lengthening  of  3  cm.  of  the  left  lower 
extremity. 

The  temperature  was  usually  0.5  of  a  degree  (Fahr.)  higher  in  the  left 
than  in  the  right  popliteal  space. 

Diagnosis. — Aneurism  of  the  external  iliac  and  femoral  arteries. 

Operation,  January  11,  1909. — Application  of  a  totally  occluding  alumi- 
num band  to  the  left  common  iliac  artery.  The  patient  was  placed  in  the 
Trendelenburg  position  to  compel  gravitation  of  the  intestines  towards  the 
thorax."  A  vertical  incision  was  made  through  the  middle  of  the  anterior 
sheath  of  the  rectus  muscle.  This  muscle  was  then  split  near  its  inner  edge, 
and  its  external  portion  retracted  outwards.  The  posterior  sheath  of  this 
muscle,  the  fascia  transversalis  and  the  peritonaeum  were  divided  about  in 
the  line  of  the  incision  through  the  anterior  sheath  and  skin. 

It  was  my  intention  to  ligate  the  external  iliac  artery  if  possible.  The 
upper  side  of  the  huge  aneurism  presented  a  vertical  face  which  seemed  to 
be  almost  flat,  and  the  external  iliac  artery  lay  at  a  great  depth  behind  the 
aneurism.  A  very  thick  panniculus  considerably  increased  the  distance  of 
the  artery  from  the  skin.  The  vertical  diameter  of  the  aneurism  at  its  upper 
edge  was  estimated  at  12  cm.  to  13  cm.  We  possessed  no  retractors  which 
could  reach  to  the  bottom  of  the  wound,  but  by  means  of  broad  spatulae  and 
the  hand  of  an  assistant,  the  intestines,  which  had  been  carefully  displaced 
upwards  and  to  the  right  side,  were  kept  easily  out  of  the  way. 

The  left  ureter  promptly  came  into  view,  and  beneath  it  the  common 
iliac  artery  was  recognized.  This  was  readily  isolated  by  means  of  two  long 
fine  blunt  dissectors,  designed  especially  for  the  dissection  of  the  deep 
arteries  (i.  e.,  the  inferior  thyroid).  The  left  common  iliac  being  raised 
from  its  bed  by  two  narrow  tapes,  an  armed  band  roller  was  passed  under  it 
in  the  usual  manner,19  and  the  band  (6  cm.  wide)  curled  by  the  instrument. 
On  releasing  the  traction-pressure  made  on  the  artery  by  the  tapes,  the 
expanded  vessel  not  only  completely  filled  the  band,  but  was  constricted  by 
it.  A  very  slight  additional  rolling  of  the  band  with  the  fingers  sufficed  to 
arrest  the  pulsation  in  the  aneurism,  but  not  altogether  in  the  common  iliac 
artery. 

The  thrill,  however,  which  is  observed  with  a  certain  amount  of  partial 
occlusion  of  an  artery  had  vanished.  A  little  additional  rolling  of  the  band — 
so  little  that  I  was  not  able  to  appreciate  with  the  fingers  that  a  further 
constriction  had  been  accomplished — shut  the  pulse  off  completely  from 
the  artery,  which  assumed  a  flattish  shape  and  the  almost  collapsed  appear- 
ance characteristic  of  empty  arteries.  The  peritonaeum,  transversalis  fascia 
and  posterior  sheath  of  the  rectus  were  closed  with  a  continuous  catgut 
suture,  and  the  anterior  sheath  of  this  muscle  in  the  same  manner.    The 

18  In  operations  upon  the  aorta  of  dogs  this  posture  was  found  to  be  of  great  service. 
"Journal  of  Experimental  Medicine,  1909,  vol.  xi,  373. 


COMMOX  ILIAC  ARTEEY  367 

subcutaneous  fascia  -was  stitched  with  interrupted  sutures  of  very  fine  silver 
wire.  A  continuous  buried  mattress  suture  of  strong  silver  wire  was  em- 
ployed for  the  skin,  because  considerable  traction  was  necessary  to  bring  its 
slightly  inflamed  edges  together  over  the  tumor.  Under  such  conditions 
catgut  is  useless,  and  silk  would  prove  a  nuisance  should  suppuration  occur. 
Where  there  is  tension  of  the  skin,  the  buried  silver  wire  suture  has  proved, 
in  our  experience,  to  be  the  best.  The  wound  was  covered  with  silver  foil. 

Returned  to  the  ward  at  1.45  p.  m.,  the  patient's  pulse  was  100,  his  tem- 
perature 97°  F.  There  was  no  return  of  pulsation  in  the  aneurism.  During 
the  afternoon  he  was  restless  and  complained  of  pain  in  the  left  leg.  The 
left  foot  seemed  cooler  than  the  right,  but  was  of  good  color,  though  the 
circulation  was  somewhat  impeded.  There  was  no  impairment  of  motion 
or  sensation. 

3.20  p.  m.  The  temperature  in  the  popliteal  space  is  97.4°  F.  on  the  left, 
97.3°  F.  on  the  right  side.  At  6  p.  m.  the  temperature  of  the  feet  is  rela- 
tively the  same  on  both  sides  as  at  3.20  p.  m.,  but  in  the  popliteal  space,  and 
for  a  short  distance  down  the  leg,  it  is  a  few  tenths  of  a  degree  higher  on 
the  left  than  on  the  other  side. 

Until  midnight  the  color  of  the  foot  remained  apparently  unchanged. 
Then  there  seemed  to  be  a  slightly  bluish  tinge  of  the  skin  of  the  left  foot, 
which  remained  for  not  more  than  two  hours.  At  no  time  did  the  patient 
observe  any  unusual  sensations  in  the  foot,  but  he  complained  of  excruciat- 
ing pain  in  the  left  leg  between  the  knee  and  ankle,  and  in  no  other  place. 
Something  seemed  to  be  "  bearing  down  on  the  bone,  hard  enough  to  break 
it."  Over  a  small  area,  about  3  cm.  in  width,  on  the  inner  side  of  the  calf 
of  the  left  leg,  the  touch  of  the  finger  could  not  be  appreciated. 

January  12th,  S  a.  m. — The  patient's  condition  is  highly  satisfactory. 
The  pain  in  the  leg  which  persisted  during  the  night  has  almost  vanished. 
The  circulation  in  the  left  foot  is  improved.  Temperature  in  popliteal  space 
96.8°  F.  on  the  left,  96.4°  F.  on  the  right  side. 

9  p.  m. — The  swelling  in  the  limb  is  diminishing;  the  measurements 
showing  2.5  cm.  decrease  in  size  at  10  cm.  and  20  cm.  above  the  patella. 

January  13th. — Patient  passed  a  comfortable  night,  with  very  little  pain 
in  the  leg.  The  foot  has  remained  warm  and  its  color  good.  There  is  little 
distension  of  the  abdomen.  At  8  a.  m.,  temperature  99.4°  F.,  pulse  120, 
respiration  20.  There  is  no  perceptible  pulsation  in  the  aneurism  or  in  the 
arteries  below.    The  tumor  seems  to  be  softer. 

8  p.  m.— Temperature  in  popliteal  space,  right  98.2°  F.,  left  98°  F. 

January  lJ+th. — Abdominal  distension  entirely  relieved. 

January  15th. — Aneurismal  mass  seems  flatter  and  softer.  There  is  no 
observable  pulsation. 

January  17th. — First  dressing.  The  tense  skin  is  reddened  along  the 
greater  part  of  incision,  about  the  middle  of  which  there  is  a  gaping  of 
nearly  4  cm.  Patient  says,  "  I  have  never  felt  better  in  my  life." 

January  20th. — The  redness  of  the  skin  has  about  disappeared.  There 
has  been  no  further  separation  of  the  edges  of  the  wound,  the  exudate  from 
which  is  still  serous.  The  swelling  of  the  leg  continues  to  decrease.  Xo 
pulsation  in  the  aneurism  or  arteries  of  the  extremity. 


368  LIGATION  OF 

January  31st. — Aneurismal  mass  measures  13.5  cm.  by  15.5  cm.  Apparent 
lengthening  of  left  leg  is  still  2  cm.  (abduction). 

February  8th. — Patient  has  been  up  in  a  chair  for  the  past  three  days. 
There  has  been  no  swelling  of  the  leg  incident  to  its  dependent  posture. 
No  pulsation  in  the  tumor.   The  wound  is  healed. 

February  10th. — Paiient  walks  without  difficulty  or  discomfort.  There  is 
no  swelling  of  the  foot. 

February  12th. — Slight  pain  in  calf,  relieved  by  massage.  Left  foot  and 
leg  slightly  cyanosed. 

February  15,  1909. — Sensation  of  entire  leg  normal,  but  at  the  inner 
side  of  the  thigh,  just  below  the  groin,  there  is  an  area  about  9  cm.  long 
over  which  the  patient  is  unable  to  distinguish  heat  and  cold  accurately, 
or  to  appreciate  the  difference  between  the  lightly  applied  point  and  the 
head  of  a  pin.  The  tumor  mass  is  smaller,  harder,  more  sharply  circum- 
scribed, and  without  pulsation.  Patient  discharged. 

January  19,  1910. — (One  year  after  the  operation.)  Patient  writes :  "I 
am  getting  along  splendidly,  and  the  aneurism  has  completely  left  me. 
I  sometimes  experience  a  little  pain  in  my  left  leg  when  walking  fast,  other- 
wise can  complain  of  nothing.  Am  very  fat,  my  weight  being  180  pounds." 

A  photograph  of  the  groin,  received  a  few  weeks  later,  shows  no  trace  of 
the  aneurism,  only  a  broad  vertical  scar. 

April  If.,  1912. — (Three  and  a  quarter  years  after  the  operation.)  Patient 
writes :  "  In  reply  to  your  letter  of  the  first,  I  will  try  to  explain  how  I  am 
feeling.  My  left  leg  is  a  great  deal  weaker  than  my  right.  I  don't  limp  any. 
I  can't  walk  very  much,  as  I  have  pains  in  my  left  leg  when  I  do  any  walk- 
ing, and  in  case  it  gets  very  cold.  My  present  weight  is  180  pounds.  I  have 
a  splendid  appetite,  and  haven't  been  ill  since  my  return.  All  traces  of  the 
aneurism  have  disappeared,  and  it  never  worries  me  the  least  bit." 

29.  (Group  II.)  Beckman,  E.  H.  Partial  occlusion  by  the  Neff  Clamp  M 
of  the  left  common  iliac  artery,  presumably  for  arterio-venous  fistula  of 
the  femoral  artery  and  vein.  (Communicated  to  me  by  Dr.  E.  H.  Beckman, 
Mayo  Clinic,  Eochester,  Minn.,  March  6,  1912.) 

Dr.  Beckman's  letter  is  as  follows : 

"  Patient  was  a  male,  27  years  of  age,  who  had  been  operated  upon  11 
years  previously  for  osteomyelitis  at  the  lower  end  of  the  left  femur.  The 
surgeon  told  him  that  the  artery  had  been  injured  at  the  time  of  operation. 
He  noticed  a  marked  thrill  in  the  femoral  artery.  The  osteomyelitis  wound 
healed  and  has  given  him  no  further  trouble.  Patient  has  had  a  marked 
thrill  and  increased  pulsation  along  the  entire  femoral  artery,  and  extending 
above  Poupart's  ligament,  from  the  time  of  his  operation,  but  he  has  been 
able  to  continue  at  work  as  a  paper-hanger.  He  consulted  us  because,  for 
the  past  three  months,  he  had  had  increased  pain  and  tenderness  along 
the  course  of  the  femoral  artery.  We  found,  upon  operative  examination, 
that  the  femoral  artery  was  dilated  to  about  the  size  of  an  aorta  throughout 
its  entire  length,  the  dilatation  extending  above  Poupart's  ligament.  At 
our  second  operation,  performed  11  days  after  the  first,  we  made  an  abdomi- 
nal incision  and  found  that  the  left  common  iliac  artery  looked  like  the 

OTJourn.  Amer.  Med.  Ass.,  1911,  lvii,  700. 


COMMON  ILIAC  AETEEY  369 

extension  of  the  aorta,  being  dilated  to  the  same  size  as  the  abdominal  aorta. 
The  right  common  iliac  artery  looked  like  a  small  branch  coming  from  the 
main  vessel. 

"A  Neff  clamp  was  applied  to  the  common  iliac  artery  just  below  the 
bifurcation  of  the  aorta,  tight  enough  to  partially  occlude  the  former  vessel, 
but  not  so  tight  as  to  arrest  the  pulsation  in  the  right  femoral  artery. 

"  It  was  thought  the  patient  also  had  a  small  tuberculous  abscess  at  the 
site  of  the  old  osteomyelitis.  This  presented  in  the  scar  of  his  original 
operative  wound  about  a  week  following  our  first  operation  and  was  drained. 
The  patient  had  several  chills,  and  ran  a  high  temperature  for  24  hours  fol- 
lowing these  chills,  but  otherwise  made  a  good  recovery. 

"  It  has  now  been  two  months  since  the  clamp  was  applied,  and  the 
patient  feels  that  he  is  very  much  improved.  He  has  returned  home  and 
will  report  to  us  from  time  to  time." 

30.  (Group  II.)  Judd,  Edward  S.  Partial  occlusion  by  the  Neff  clamp 
of  the  right  common  iliac  artery  for  aneurism  of  the  external  iliac.  Death. 
(Communicated  to  me  by  Dr.  Edw.  S.  Judd  and  Dr.  B.  F.  McGrath,  Mayo 
Clinic,  Eochester,  Minn.,  March  25,  1912.)    Dr.  Judd's  letter  is  as  follows: 

"  Case  61582.  Male  aet.  28.  Examined  at  the  Mayo  Clinic,  November  27, 
1911. 

"  Previous  History. — Ten  years  ago,  pneumonia.  Six  years  ago,  operation 
for  right  inguinal  hernia. 

"  Subjective  Symptoms. — For  the  past  year  the  patient  has  felt  a  throb- 
bing sensation  in  the  right  side  of  the  abdomen,  about  two  inches  above  the 
hernial  wound.  Three  weeks  ago,  and  occasionally  since  then,  he  has  suf- 
fered from  sharp  pleuritic-like  pains  in  the  same  region  on  lifting.  Other- 
wise feels  well. 

"  Objective  Signs. — There  is  a  pulsating  mass  in  the  lower  abdomen, 
slightly  to  the  right  side.  A  bruit  is  heard  over  the  mass.  Pulsation  of  both 
femoral  arteries  is  absent.  The  mass  pushes  into  the  anterior  wall  of  the 
rectum,  low  down.  The  inguinal  glands  of  both  sides  are  enlarged.  The 
right  leg  is  somewhat  swollen.  The  lower  abdominal  veins  are  prominent. 
A  scar  resulting  from  the  operation  for  right  inguinal  hernia  is  present. 
X-ray  negative;  Wassermann,  negative. 

"Admitted  to  St.  Mary's  Hospital,  December  6,  1911,  for  observation. 
Temperature  and  pulse  normal  to  time  of  operation. 

"  Operation,  December  29,  1911. — A  low  abdominal  exploratory  incision 
was  made  to  the  left  of  the  mid-line.  An  aneurismal  sac  occupied  nearly  the 
entire  pelvis  and  bulged  over  the  pelvic  brim,  thereby  obscuring  its  exact 
origin,  but  affording  the  observation  that  it  arose  from  the  right  side  of 
the  pelvis. 

"  A  long  oblique  incision  was  then  made  in  the  right  loin,  exposing,  but 
not  opening,  the  peritonaeum.  The  latter  was  reflected,  the  aorta  exposed 
and  the  right  common  iliac  artery  reached  by  the  guidance  of  the  pulsating 
wall  of  the  aneurismal  sac.  The  right  ureter  and  the  right  common  iliac 
vein  were  isolated,  pushed  aside,  and  a  Neff  occlusion-clamp  applied  to  the 
common  iliac  artery  about  one  inch  above  the  aneurism.  The  clamp  was 
then  gradually  closed  until  but  a  faint  pulsation  of  the  tumor  was  noted. 
25 


370 


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nda.     The    ext.    iliac    ligated   above 
stric  and  probably  above  circumflex 
also.    Amputation.     Cure.    Observed 
rs. 

the  four  cases  in  Group  I  of  recovery 
ligation  of  common  iliac  for  haemor- 
,  and  the  only  case  in  this  group  (if 
ace  Dequise's  in  Group  II)  recovered 
ut   gangrene.     "  Cure."     Observed   9 
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?d    Neff    clamp,    partially    occluding 
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or  osteomyelitis  of  femur. 

mployed    Neff    clamp,    partially    occluding 
the    common    iliac    artery.     Aneurism    be- 
lieved to  have  resulted  from  an  operation 
for  hernia  performed  six  years  previously. 

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COMMON  ILIAC  ARTERY  373 

"Post-operative  Course. — The  pulse  was  130  for  several  hours  after  the 
operation,  and  then  varied  between  this  and  162  until  the  end.  Vomiting 
for  the  first  24  hours.  Severe  pain  in  the  right  leg.  Pulsation  of  femorals 
absent.  Color  of  right  leg  good  for  two  days.  Died,  January  1,  1912. 

"Autopsy. —  (B.  F.  McGrath.)  An  incision  to  the  left  of  the  mid-line, 
15  cm.  long,  is  firmly  closed  with  suture.  This  region  is  bulging,  and  there 
is  some  ecchymosis  about  the  suture  line.  In  the  depth  of  the  same  incision 
is  a  considerable  number  of  clots,  apparently  the  result  of  venous  oozing. 
On  the  right  side  is  a  closed  oblique  incision  about  19  cm.  long,  passing  in 
front  of  the  anterior  superior  spine  of  the  ilium;  this  incision  extends  to, 
but  not  through,  the  peritonaeum.  The  right,  lower  extremity  is  very  much 
swollen.    On  the  inner  side  of  the  thigh  there  is  venous  thrombosis. 

"  Thorax. — Lungs  and  pleural  cavities,  nothing  noteworthy.  The  heart 
is  somewhat  enlarged,  otherwise  it  presents  no  changes. 

"Abdomen. — Liver,  moderate  degeneration.  Kidneys,  considerable  acute 
nephritis.  A  tumor  extends  from  the  umbilicus  to  the  left  side  of  the  pelvis 
and  down  to  the  right  groin.  A  Neff  occlusion-clamp  is  in  position  on  the 
right  common  iliac  artery  3  or  4  cm.  from  the  bifurcation  of  the  aorta. 
About  2.5  cm.  below  the  clamp  the  artery  passes  into  the  tumor,  which 
proves  to  be  an  aneurism  of  the  right  iliac,  its  inferior  extremity  extending 
to  about  the  beginning  of  the  femoral  artery.  The  left  pelvic  portion  of 
the  tumor  consists  of  a  fist-sized  fatty  mass,  rather  lightly  attached  to  the 
aneurismal  sac.  The  aneurism  contains  dark  clotted  blood,  which  is  partially 
organized,  and  somewhat  occludes  the  lumen. 

"  Within  the  artery  and  directly  beneath  the  aneurism  is  a  valve-like  pro- 
jection from  the  posterior  wall  of  the  vessel.  The  lateral  and  anterior  edges 
of  the  projection  are  thin  and  unattached,  but  in  contact  with  the  vascular 
wall.  Its  upper  surface  is  somewhat  concave,  and  receives  the  lower  end  of 
the  organized  blood  clot.  Its  structure  is  of  nearly  cartilaginous  consis- 
tency, and  the  neighboring  lining  of  the  vessel  is  roughened  and  firm; 
sections  from  this  area  show  principally  dense  fibrous  tissue. 

"  At  the  autopsy  nothing  was  found  to  account  for  the  patient's  death. 
The  operation  was  an  extremely  difficult  one,  and  required  considerable  time, 
and  while  the  patient  reacted  fairly  well,  the  reaction  was  not  complete. 
I  think  there  is  no  possible  chance  that  the  clamp  could,  even  partially,  have 
occluded  the  aorta." 

In  the  opinion  of  Dr.  Judd  the  operation  for  hernia,  six  years  ago,  was 
responsible  for  the  aneurism. 

Gaxgkexe 

In  the  thirty-two  cases  operated  upon  prior  to  1860,  reported  by  Stephen 
Smith,  gangrene  of  the  leg  or  foot  occurred  in  five  or  15.6  per  cent.  But  on 
study  of  the  reports  of  these  cases,  I  find  that,  probably,  in  only  a  single 
instance  might  the  gangrene  be  attributed  to  ligation  of  the  common  iliac. 
The  cases  are  as  follows : 

1.  Group  I.  (No.  7,  Smith.)  C.  W.  F.  Uhde,  Braunschweig.  (Deutsche 
Klinik,  No.  16,  April,  1853.) 


374  LIGATION  OF 

2.  Group  II.  (No.  4,  Smith.)  M.  Salomon,  St.  Petersburg.  (Zeitschrift 
f.  d.  Gesammte  Medicin,  Bd.  12,  Heft  3,  1839.) 

3.  Group  II.  (No.  5,  Smith.)  James  Syme.  (Edinburgh  Medical  and 
Surgical  Journal,  October,  1838.) 

4.  Group  II.  (No.  11,  Smith.)  A.  J.  Wedderburn,  New  Orleans.  (New 
Orleans  Medical  and  Surgical  Journal,  May,  1852.) 

5.  Group  III.  (No.  4,  Smith.)  C.  Th.  Meier,  New  York.  (New  York 
American  Medical  Gazette,  May,  1859.) 

Ad.  1.  Aneurism  of  the  left  gluteal  artery;  rupture  of  the  internal  iliac 
in  attempt  to  ligate  it;  ligature  of  common  iliac  artery.  Death  on  fourth 
day  after  operation. 

Autopsy. — "Internal  iliac  ruptured;  indications  of  peritonitis,  leg 
oedematous,  calf  red,  showing  signs  of  approaching  gangrene." 

In  this  case  gangrene  did  not  actually  develop,  notwithstanding  the  fact 
that  the  patient  died  on  the  fourth  day.  There  were  merely  indications,  and 
at  the  autopsy,  of  approaching  gangrene.  Had  the  patient  lived,  even  these 
"  signs  "  might  not  have  manifested  themselves.  Note  that  the  internal 
iliac  artery  was  ruptured  and  not  ligated  and  that  five  pounds  of  blood 
were  lost.  At  autopsy  the  tissues  about  the  sac  were  infiltrated  with  blood, 
and  many  pockets  of  blood  were  found  in  the  muscles.  Even,  therefore,  had 
gangrene  developed  during  life,  it  would  not  have  been  attributable  solely 
to  the  ligation  of  the  common  iliac. 

Ad.  2.  Aneurism  of  the  left  external  iliac  artery;  ligature  of  the  common 
iliac.  Recovery. 

The  aneurism  was  traumatic,  caused  by  the  kick  of  a  horse.  It  extended 
from  four  fingers'  breadth  above  to  the  same  distance  below  Poupart's  liga- 
ment ;  in  the  region,  therefore,  in  which  important  anastomotic  vessels  are 
located.  The  pulsation  ceased  and  the  tumor  rapidly  diminished  in  size 
after  the  ligation  of  the  common  iliac,  and  the  limb  which  became  cool  at 
first  regained  its  natural  warmth.  In  this  patient,  nothing  more  than  gan- 
grenous eschars  appeared  on  the  foot  which  subsequently  healed.  It  is  to  be 
noted  that  the  situation  of  the  aneurism  in  this  case  was  approximately 
the  same  as  in  Wedderburn's  (4),  but  in  the  former  it  may  have  been  of  the 
sacculated  variety." 

The  case  is  reported  in  great  detail  by  Salomon  in  the  quaint  little  Zeit- 
schrift fur  die  Gesammte  Medicin,  sometimes  referred  to  as  Oppenheim's 
Zeitschrift. 

n  From  Salomon's  account  of  the  post-mortem  examination,  "  Die  Pulsader-ge- 
schwulst  hatte  ihren  Ursprung  gleich  oberhalb  des  Ligamentum  Poupartii  genommen 
und  sich  auf-und  abwarts  verbreitet." 


COMMON  ILIAC  ARTERY 


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376  LIGATION  OF 

The  patient  died  ten  months  after  the  operation  from  "psoitis  rheu- 
matica  " — a  suppurative  inflammation  in  the  course  of  the  psoas  muscle  on 
the  affected  side. 

Very  instructive  are  the  findings  at  autopsy  relative  to  the  collateral  cir- 
culation after  ligation  of  the  common  iliac.  Salomon  injected  the  descend- 
ing aorta  with  a  wax  mass. 

"  The  injected  wax  mass  had  passed  into  both  lower  extremities.  The 
arteria  iliac  communis  sinistra  had  been  ligated  about  one-half  inch  below 
the  bifurcation  of  the  aorta  abdominalis,  as  was  proved  by  the  obliterated 
and  narrowed  portion  of  the  common  iliac ;  moreover,  throughout  its  entire 
course,  this  artery  was  converted  into  a  ligamentous  substance;  into  the 
arteria  iliaca  externa  sinistra  some  of  the  wax  mass  had  been  forced  by  way 
of  the  arteria  hypogastrica  sinistra  (left  internal  iliac).  The  collateral  cir- 
culation above  the  ligature  had  been  carried  on  by  means  of  the  greatly 
dilated  lowest  arteria  lumbalis  (ilio-lumbar)  whose  branches  communicated 
with  those  of  the  arteria  circumflexa  iliaca  sinistra.  The  left  lower  extremity 
received  its  arterial  blood  principally  through  the  branches  of  the  arteria 
hypogastrica  sinistra,  which  communicated  freely  with  those  of  the  right 
side,  so  that  the  injected  mass  by  way  of  these  had  penetrated  into  the  vessels 
of  the  left  thigh;  the  arteria  femoralis  was  filled  with  wax  to  about  two 
inches  below  Poupart's  ligament.  The  arteria  iliaca  communis,  iliaca  externa 
and  hypogastrica  of  the  right  side  were  greatly  dilated.  In  the  left  thigh 
the  branches  of  the  obturator  and  ischiadic  arteries  were  particularly 
enlarged/' 

These  observations  of  Salomon's  are  instructive  in  that  they  demonstrate 
the  importance  of  the  obturator  and  sciatic  arteries,  of  the  anastomoses 
between  the  internal  iliac  arteries  of  the  two  sides,  and  between  the  circum- 
flex iliac  and  ilio-lumbar  arteries  of  the  same  side.  No  mention  is  made 
of  the  condition  of  the  deep  epigastric  artery. 

Ad.  3.  Aneurism  of  the  right  external  iliac  artery.  Mortification  of  the 
limb  and,  subsequently,  ligation  of  the  common  iliac  artery. 

Here  the  gangrene  preceded  the  operation  and  almost  necessarily  increased 
in  extent  after  it. 

Ad.  4.  Aneurism  of  the  left  femoral  and  external  iliac  artery.  Ligation 
of  the  common  iliac. 

Severe  haemorrhage  during  the  operation  and  death  on  the  fourth  day. 
Gangrene  below  the  knee  on  the  second  day;  extended  to  the  hip  on  the 
fourth  day.   Pulsation  ceased  in  the  aneurism. 

This  was  an  aneurism  which,  perhaps,  gave  off  all  the  important,  anas- 
tomotic branches — the  epigastric,  circumflex  iliac,  profunda,  internal  and 
external  circumflex  arteries — above  and  below  Poupart's  ligament. 

The  great  loss  of  blood  during  the  operation  may  have  enfeebled  the 
patient  to  an  extreme  degree  and  predisposed  to  the  gangrene,  which  was 


COMMON  ILIAC  ARTERY  3?  7 

too  great  in  extent  to  be  conceived  of  as  due  solely  to  occlusion  of  the  com- 
mon iliac. 

The  original  account  of  this  case  which  was  reported  under  the  heading 
"  Editorial  " — "  City  Intelligence,"  is  meagre,  and  was,  presumably,  not 
written  by  the  operator,  Wedderburn.  As  to  the  findings  at  autopsy,  noth- 
ing is  said  of  the  condition  of  the  branches  of  the  external  iliac  and  femoral 
arteries  nor  is  the  precise  extent  of  the  aneurism  given.  In  the  account  of 
the  operation,  it  is  mentioned  that  the  aneurism  extended  to  within  one  or 
two  inches  of  the  bifurcation  of  the  primitive  iliac  artery. 

Probably  there  was  extensive  thrombosis  of  veins  and  arteries ;  and,  as  I 
have  said,  it  is  likely  that  all  the  arteries  important  for  the  anastomotic 
circulation  opened  into  the  aneurismal  sac  and  became  obliterated  after  the 
ligation.  It  is  an  established  fact  that  the  life  of  the  limb  may  be  imperiled 
by  the  cure,  per  se,  of  an  aneurism. 

Ad.  5.  Patient,  aet.  59.  Immense  osteo-aneurism  of  the  pelvis,  gluteal 
region  and  femur.   Ligation  of  common  iliac. 

Second  day,  discoloration  of  the  wound  and  thigh;  third  day,  increasing 
discoloration;  fourth  day,  wound  dark  and  neighboring  parts  inflamed; 
toes  and  sole  of  foot  black;  gangrene  continued  to  the  hip.  Gangrene 
appeared  first  about  the  wound.  At  autopsy,  peritonitis  was  found.  In  this 
case,  it  would  not  be  justifiable  to  assume  that  the  ligation  of  the  common 
iliac  artery  was  alone  responsible  for  the  gangrene. 

Only  in  case  2,  therefore,  might  it  be  reasonably  supposed  that  the  ligation 
of  the  artery  was  the  sole  cause  of  the  gangrene ;  and  in  this  patient  there 
were  merely  eschars  which  healed  without  surgical  interference.  It  is  to  be 
borne  in  mind  that  the  wounds  in  all  of  these  cases  were  infected. 

To  Stephen  Smith's  32  cases  (from  1827-1860)  Kummel"  adds  15  from 
the  septic  era. 

To  Group  1,  3  cases,  from  1863-1865  (Nob."  13,  14  and  15).  In  none  of 
these  was  there  gangrene.  In  Case  No.  14  amputatio  femoris  was  done 
before  the  ligation  of  the  common  iliac  and  hence  it  is  not  pertinent  to  the 
subject  under  consideration. 

To  Group  II,  12  cases,"  from  1861-1875  (Ho,  35,  36,  37,  38,  39,  40,  41, 
42,  43,  44,  45,  46).  In  only  two  of  these  (Cases  39  and  41)  is  mention  made 
of  gangrene. 

Ad.  39.  Hargrave/*  Arterio-venous  aneurism  of  the  external  iliac  vessels. 
Ligature  of  the  common  iliac  artery. 

"Archiv.  f.  klin.  Chirurgie,  1SS4,  p.  66. 

15  Consult  original  article  for  Cases  57,  58,  59,  60,  61,  62  in  Kiimmel's  appendix. 

"Dublin  Med.  Press,  1865,  vol.  ii. 


378  LIGATION  OF 

A  large  pulsating  tumor  of  the  left  iliac  fossa  which  had  been  treated  in 
vain  by  digital  and  instrumental  compression.  On  the  29th  day  after  opera- 
tion, dry  gangrene  of  the  foot  began.  On  the  45th  day  all  the  toes  were 
mummified.  The  gangrene  extended,  and  the  extremity  became  oedematous, 
as  high  as  the  hip  joint.  On  the  67th  day  large  pelvic  abscesses  were  opened 
on  both  sides,  and  great  quantities  of  foul-smelling  pus  evacuated.  Arterial 
haemorrhage  from  the  right  abscess  on  the  71st  day.  On  the  73d  day  recur- 
rence of  the  haemorrhage  and  death. 

Note  that  the  aneurism  was  of  the  arterio-venous  variety  and  probably 
included  the  epigastric  and  circumflex  and  iliac  vessels,  that  there  was  very 
extensive  suppuration  in  the  pelvis,  and  that  gangrene  did  not  begin  until 
the  29th  day. 

Ad.  41.  Maundner.25  Ligation  of  the  common  iliac  artery  for  aneurism 
of  the  right  external  iliac.  Death  on  the  60th  day  from  gangrene  of  the 
corresponding  extremity. 

The  common  iliac  vein  was  obliterated. 

From  the  years  between  1875  and  1884,  Kummel  reports  only  4  cases 
(all  antiseptically  treated)  of  ligation  of  the  common  iliac  artery,  two 
being  his  own.   Gangrene  occurred  in  three  (75  per  cent)  of  these  cases. 

1.  Group  I.  No.  16,  Kummel.  (Archiv.  f.  klinische  Chirurgie,  1884, 
p.  67.) 

2.  Group  II.  No.  47,  C.  M.  Eichter.  (Pacific  Medical  and  Surgical 
Journal,  1881,  p.  505.) 

3.  Group  II.  No.  48,  Nicoladoni.  ( Sulzenbacher,  Wiener  med.  Presse, 
1882,  Nos.  7-9.) 

4.  Group  II.   No.  56,  Kummel.    (Loc.  cit.) 

Ad.  1.  Haemorrhage  from  erosion  of  the  femoral  artery,  following  opera- 
tion for  bubos,  and  diphtheritic  infection  of  the  wound.  The  femoral  artery 
was  ligated  three  times,  the  external  iliac  artery  twice,  and  ultimately  the 
profunda  and  circumflex  arteries.  Gangrene  of  the  leg.  Amputation. 
Recovery. 

Not  only  were  all  of  the  above  vessels  ligated,  in  addition  to  the  common 
iliac,  but  the  patient's  vitality  had  been  greatly  lowered  by  repeated  and 
excessive  haemorrhages.  Gangrene  beginning  in  the  foot,  on  the  day  after 
the  ligation  of  the  profunda  and  the  third  ligation  of  the  femoral  (12  days 
after  the  ligation  of  the  common  iliac)  had  extended  more  than  half  way 
up  the  leg  on  the  third  day.  In  this  case,  certainly,  the  ligation  of  the 
common  iliac  artery  was  not  alone  responsible  for  the  gangrene. 

Ad.  2.  Aneurism  of  the  external  iliac.  Ligature  of  the  common  iliac. 
Gangrene  of  the  leg.   Recovery. 

"Med.  Times  &  Gazette,  Oct.,  1867  (Maundner). 


COMMON  ILIAC  ARTERY  379 

The  aneurism,  as  large  as  the  head  of  a  child,  was  non-pulsating.  The  leg 
of  the  affected  side  was  twice  the  size  of  the  other.  Ligation  of  the  common 
iliac  was  undertaken  because  gangrene  was  beginning  and  the  aneurism 
was  increasing  in  size.   Note  that  the  gangrene  antedated  the  operation. 

Ad.  4.  Aneurism  of  the  inguinal  region  and  of  the  calf  of  the  leg.  Burst- 
ing of  the  latter  aneurism.  Ligation  of  the  external  iliac.  Subsequent 
haemorrhage.  Ligation  of  the  common  iliac.  Death  in  12  hours. 

Gangrene  of  the  calf  of  the  leg  in  the  infiltrated  tissues  along  the  rup- 
tured aneurism,  occurred  before  the  ligation  of  the  common  iliac  artery. 
In  not  one  of  the  three  cases,  therefore,  was  uncomplicated  ligation  of  the 
common  iliac  artery  responsible  for  the  gangrene. 

For  the  nine  years  from  1884,  the  date  of  Kummel's  paper,  to  1903,  the 
year  of  his  own  communication,  Dreist  was  able  to  add  only  6  cases  to 
Groups  I  and  II,  none  to  Group  III.  One  of  these  (Trendelenburg's)  died 
of  haemorrhage  three  hours  after  the  operation.  In  two  (Christel's  and 
v.  Varendorrf's)  of  the  remaining  five  gangrene  occurred  (40  per  cent), 
but  it  was  not  due,  primarily,  to  ligation  of  the  common  iliac  in  either  case. 

1.  Group  I.    (No.  3,  Christel,  1901,  he.  cit.,  p.  6.) 

2.  Group  II.    (No.  5,  v.  Varendorrf,  1898.  Dissertation,  Marburg,  1899.) 
Ad.  1.    Spurious  aneurism,  presumably  of  the  femoral  artery,  caused  by 

splinter  of  iron.  Ligation  of  the  left,  common  iliac  artery.  Gangrene  of 
leg.  Recovery. 

Greatly  emaciated  patient;  pulse  126-130;  temperature  34.7°.  Left  thigh 
tremendously  swollen,  the  tumefaction  extending  from  knee  to  navel.  In  the 
course  of  the  operation,  the  external  iliac  was  twice  ligated.  The  epigastric 
artery  which  was  given  off  from  the  external  iliac  between  the  two  ligatures 
was  also  ligated.  Finally  a  ligature  was  placed  on  the  common  iliac  artery ; 
as  further  peril  to  the  circulation  of  the  leg  there  was  deep  suppuration  of 
the  oedematous  thigh.  To  attribute  the  gangrene  in  this  case  to  ligation  of 
the  common  iliac  would  be  unreasonable. 

Ad.  2.  Injuries  and  aneurisms  of  the  gluteal  and  sciatic  arteries.  Ligation 
of  the  left  common  iliac  artery.   Gangrene.  Death. 

Woman,  aet.  66.  Pulsating  tumor  as  large  as  a  child's  head  in  the  left 
ischiadic  region.  Attempt  made  by  the  operator  to  ligate  all  the  vessels 
contributing  to  the  aneurism  and  to  extirpate  the  sac  (Philagrius). 
Accidental  tearing  of  the  sac.  Ligation  of  the  internal  iliac  artery  which 
proved  to  be  the  seat  of  a  fusiform  aneurism.  Immediately  upon  discovery 
of  this,  ligation  of  the  common  iliac  artery  which,  in  turn,  presented  several 
small,  fusiform  dilatations  of  its  calcified  wall.  Extirpation  of  the  sac  and 
of  two-thirds  of  the  imbedded  sciatic  nerve.  Tamponade.  On  the  second 
day,  gangrene  of  the  entire  leg.   On  the  fourth  day,  death.  The  ligation  of 


380  LIGATION  OF 

the  common  iliac  was,  accordingly,  only  one  of  the  several  factors  which 
contributed  to  the  gangrene. 

In  Kiimmel's  collection  (1884),  only  four  cases  in  Groups  I  and  II  are 
from  antiseptic  times  (Nos.  2,  3,  5,  and  7  of  my  Table  A).  As  I  have  said, 
in  three  of  these  (two  of  them  his  own)  gangrene  occurred,  but  in  two  of 
the  three  the  gangTene  had  manifested  itself  before  the  ligation  of  the  com- 
mon iliac.  The  number  of  his  cases  is  too  small  for  statistical  purposes. 

For  Groups  I  and  II  in  the  antiseptic  era,  Dreist,  1903  (loc.  cit.),  col- 
lected ten  cases — five  for  each  group.  Five  of  these  had  gangrene.  Hence  he 
concludes  that  "  the  chief  danger  "  from  ligation  of  the  common  iliac  artery 
"  is  still  today  the  gangrene  which  results  in  its  consequence." 

Gillette  in  1908  {loc.  cit.)  could  add  only  one  case  (Martin's)  beside  his 
own  to  the  collection  made  by  Dreist  in  1903.  He  makes  the  statement 
that  "  gangrene  of  the  leg  has  occurred  in  the  last  twenty-one  cases  seven 
times,  or  in  33£  per  cent." 

Matas,  in  a  masterly  article  of  333  pages  on  the  Surgery  of  the  Vascular 
System  (Keen's  Surgery,  1909,  Vol.  V,  p.  337),  writing  of  ligation  of  the 
common  iliac  artery,  says  that  "  In  the  21  operations  done  since  1880,  pre- 
sumably with  antiseptic  precautions,  gangrene  occurred  7  times,  or  in 
33.33  per  cent." 

Gillette  and  Matas  must  have  included  in  their  calculations  ligations  of 
the  common  iliac  artery  performed  with  objects  in  view  other  than  the 
arrest  of  haemorrhage  and  the  cure  of  aneurism,  cases  complicated,  some 
of  them,  by  desperate  operations  such  as  disarticulatio  interilio-abdominalis, 
and  which  belong  to  the  Groups  III  and  IV  of  Stephen  Smith. 

In  the  thirty  cases  (Groups  I  and  II)  of  ligation  of  the  common  iliac 
artery  published  since  1880,  and  collected  in  this  paper,  gangrene  has 
occurred  twelve  times,  or  in  40  per  cent  (vid.  Table  B). 

Table  B  has  been  arranged  to  enable  the  reader  to  see  at  a  glance  *  the 
factors  other  than  the  ligation  of  the  common  iliac  artery  which  have  been 
instrumental  in  the  production  of  the  gangrene. 

Two  of  the  twelve  cases  (Nos.  1  and  5),  can  be  excluded  because  the  gan- 
grene had  manifested  itself  before  the  ligation  of  the  common  iliac  was 
undertaken. 

In  one  (No.  9)  signs  of  gangrene  ("  blue  spots  ")  appeared  on  the  fourth 
day  when  the  patient,  aged  and  exsanguinated,  was  almost  moribund.  She 
died  the  following  day.  In  this  case,  the  sac  of  a  sciatic  aneurism  had  been 
excised. 

M  The  reader  is  referred  also  to  the  abstracts  which  I  have  made  of  these  cases. 


COMMON  ILIAC  ARTERY  381 

In  Case  4  the  gangrene,  which  consisted  in  the  casting  off  of  sloughs,  was 
confined  to  the  operative  wound,  and  its  environs,  and  was  due  to  an  intense 
local  infection.  There  was  no  gangrene  of  the  foot  or  leg. 

Perhaps  the  most  striking  instance  in  the  literature  of  the  extent  to 
which  the  main  arteries  may  be  tied  without  manifest  disturbance  of  the 
circulation  of  the  limb  is  furnished  by  a  case  of  Rummer's  (Table  B,  No.  3). 
In  this  patient,  who  was  exsanguinated  by  terrific  haemorrhage  almost  to 
the  point  of  death,  there  were  ligated  the  common  iliac,  the  deep  epigastric, 
and  the  circumflex  iliac,  the  external  iliac  twice,  and  the  femoral  three  times, 
and  all  without  the  production  of  signs  of  gangrene.  It  was  not  until  eleven 
days  after  the  ligation  of  the  common  iliac  and  when  three  vessels  in  the 
neighborhood  of  the  profunda  femoris  had  been  tied,  that  gangrene 
supervened. 

Gouley's  case,  No.  6,  although  not  published  until  1885,  was  operated 
upon  in  1871,  in  the  highly  septic  times.  The  patient  died  of  infection  on 
the  21st  day,  the  gangrene  manifesting  itself  not  until  48  hours  before  death. 

In  No.  7,  the  case  of  Thos.  Smith,  there  were,  as  complications  resulting 
from  infection,  thrombosis  of  the  external  iliac,  femoral  and  profunda  veins, 
and  of  the  internal  iliac,  femoral  and  profunda  arteries.  The  aneurism  in- 
volved the  femoral  as  well  as  the  external  iliac  artery  and  was  of  the  fusi- 
form variety.  I  should  think  that,  in  this  locality,  ligation  of  the  common 
iliac  for  the  obliteration  of  a  fusiform  aneurism  might  be  more  likely  to  be 
followed  by  gangrene  than  if  performed  for  the  cure  of  a  sacculated  aneu- 
rism, because  from  the  fusiform  variety,  the  deep  epigastric,  the  circumflex 
iliac  and  the  profunda  arteries  are  given  off,  which  they  may  not  be  in  the 
case  of  the  sacculated  or  spurious  varieties  (vid.  also  Cranwell's  case, 
No.  11). 

In  Meyer's  case,  No.  8  (ligation  of  the  external  and  both  of  the  internal 
iliac  arteries),  infection  and  haemorrhage  should  be  regarded  as  factors 
contributing  to  the  gangrene  which  involved  only  the  toes,  and  these  only 
in  part. 

No.  10,  Christel.  In  this  instance  it  is  clear  that  the  complications  must 
have  been  largely  influential  in  the  production  of  gangrene.  Profuse  haemor- 
rhage occurred  in  the  course  of  the  operation.  The  external  iliac  artery 
was  ligated  both  above  and  below  the  origin  of  the  deep  epigastric  and 
circumflex  iliac  arteries,  the  latter  of  these  being  independently  tied.  There 
was  extensive  extravasation  of  blood,  the  thigh  was  enormously  swollen  and 
the  tissues  infected.  The  aneurism  was  of  the  femoral  artery  and  probably 
involved  the  profunda. 

No.  12.  Gillette  ligated  the  internal  and  external  iliac  arteries,  as  well 
as  the  parent  stem  and  excised  an  aneurism  of  the  sciatic. 


382  LIGATION  OF 

In  ten  of  the  twelve  cases,  therefore,  it  would  be  unfair,  indeed  absurd, 
to  attribute  the  gangrene  to  the  ligation  of  the  common  iliac  artery. 

The  cases  of  Lange  and  Cranwell  remain  to  be  considered.  In  one  of 
these,  Lange's  (No.  2),  there  seems  to  have  been  no  complication  and  we 
must  assign  as  cause  for  the  gangrene  the  ligation  of  the  common  iliac  artery. 
The  gangrene  was,  however,  very  trivial,  involving,  as  it  did,  only  the  skin 
of  the  great  toe. 

The  situation  of  the  aneurism  may  have  been  a  factor  in  the  determination 
of  the  gangrene.  It  involved  the  femoral  as  well  as  the  external  iliac  arteries. 

CranwelPs  case  (No.  11)  is  the  only  one  known  to  me,  operated  upon  in 
antiseptic  times,"  in  which  significant  gangrene  has  occurred  after  ligation 
of  the  common  iliac  artery  not  complicated  by  other  factors  contributing 
to  the  serious  disturbance  of  the  circulation  in  the  limb.  The  publication 
is  in  Spanish.  The  case  seems  to  be  fully  reported  and  well  presented  and 
I  have  no  reason  for  believing  that  there  is  anything  to  be  read  between  the 
lines.  As  stated  in  the  text  and  shown  in  a  semidiagrammatic  illustration, 
the  internal  iliac  artery  was  compressed,  possibly  occluded,  by  the  aneurism 
which  involved  not  only  the  entire  external  iliac  but  also  the  femoral  artery. 
It  was  noted  before  operation  that  the  thigh  and  leg  were  oedematous,  that 
there  was  general  arteriosclerosis  and  that  the  patient's  condition  was  bad. 
The  aneurism  had  existed  for  fifteen  and  perhaps  for  thirty  years.  Attacks 
of  cramps  in  the  limb  of  the  affected  side,  severe  enough  to  prevent  locomo- 
tion, had  been  present  for  thirty  years  (conf.  abstract). 

The  case  is  a  remarkable  one,  but  must  nevertheless  be  accepted  for  the 
present  as  furnishing  an  instance  of  the  production  of  gangrene  from  liga- 
tion of  the  common  iliac  artery. 

Granting  that  in  the  case  of  Lange  and  Cranwell  the  ligation  of  the 
artery  was  solely  responsible  for  the  gangrene,  we  have  only  two  such  cases 
in  the  thirty  of  my  collection,  a  percentage  of  six  and  six  tenths. 

If  it  should  appear  later  that  Cranwell's  case  might,  for  unascertained 
reasons,  be  excluded,  the  percentage  would,  of  course,  be  three  and  three 
tenths,  and  the  sum  total  of  gangrene  the  cutaneous  necrosis  of  one  toe. 

The  Anastomotic  Circulation 

It  would  involve  much  labor  to  determine  what  the  actual  danger  of  gan- 
grene is  from  ligation  of  the  various  arteries.  The  factors  contributing  to 
the  gangrene  in  each  reported  case  would  have  to  be  duly  considered. 

The  percentages  have  been  computed  by  many  authors  and  although 
between  the  minimum  and  maximum  estimates  there  may  be  great  variation, 

"  Antiseptic  precautions  were  presumably  observed. 


COMMON  ILIAC  ARTERY  383 

there  seems  to  be  little  doubt  as  to  the  relative  frequency  with  which  gan- 
grene has  manifested  itself  after  ligation  of  one  as  compared  with  another 
of  the  principal  vessels  of  the  extremities. 

There  is  abundant  evidence  in  support  of  the  view  that,  in  a  general  way, 
the  larger  the  artery,  or  the  nearer  it  is  to  the  heart,  the  less  the  impairment 
of  the  circulation  attending  its  ligation.  The  subclavian,  for  example,  may 
be  tied  quite  without  fear  of  gangrene,  whereas  from  ligation  of  the  axillary 
artery  the  circulation  of  the  extremity  is  somewhat  endangered,  but  not  so 
much  as  from  ligation  of  the  brachial. 

Peripheral  gangrene  has  not  been  observed  in  consequence  of  ligation  of 
the  aorta.  It  may  occur  after  ligation  of  the  common  iliac,  has  occurred 
much  more  frequently  after  ligation  of  the  popliteal  artery  in  a  considerable 
percentage  of  the  cases. 

Kummel,  offering  the  generally  accepted  explanation  of  the  imperfect 
law,  writes: 

"  It  seems,  naturally  within  certain  limits,  that  the  nearer  the  ligated 
vessel  is  to  the  central  organ  of  the  circulation,  the  easier  it  is  for  the  col- 
lateral routes,  by  means  of  the  increased  pressure  from  the  heart,  to  develop ; 
this  certainly  seems  to  hold  true  of  the  vessel  which  we  are  considering 
(common  iliac). 

"  Astonishing  as  it  may  seem,  it  nevertheless  appears  to  be  a  fact,  as 
already  stated,  that  the  ligation  of  the  common  iliac  less  endangers  the 
vitality  of  the  lower  extremity,  and  makes  easier  the  establishment  of  the 
collateral  circulation  than  does  the  ligation  of  a  peripheral  vessel,  for 
example,  the  external  iliac. 

"  I  do  not  hesitate,  therefore,  in  the  case  of  aneurisms  of  the  external 
iliac  and  high  femoral  arteries,  to  express  a  preference  for  the  ligation  of 
the  common  iliac,  even  when  ligation  of  the  external  iliac  is  possible,  for, 
thereby,  the  definite  cure  of  the  aneurism  seems  to  be  more  certain  of  accom- 
plishment, and  the  life  of  the  limb  is  less  endangered/' 

Surely  one  would  not,  with  the  hope  of  diminishing  the  danger  of  gan- 
grene and  in  order  to  produce  a  condition  equivalent  to  the  tying  off  of 
the  parent  trunk,  ligate  the  internal  iliac  after  ligation  of  the  external  iliac 
had  been  made.  Ligation  of  the  common  iliac  is  not,  of  course,  equivalent 
to  ligation  of  the  external  and  internal  iliacs,  unless  one  or  the  other  of 
these  branches  is  obturated  at  a  lower  point,  as  by  aneurism ;  or  unless  they 
are  ligated  so  close  to  the  parent  stem  that  no  blood  can  pass  from  one  to 
the  other  over  the  spur  of  bifurcation. 

May  it  not  be,  inasmuch  as  in  the  cure  (spontaneous  or  operative),  per  se, 
of  certain  aneurisms  there  lies  danger  to  the  life  of  the  limb,  that  the  par- 
ticular situation  of  the  aneurism  may  be  an  important  factor  in  the  determi- 
nation of  gangrene,  and  that,  for  example,  the  aneurisms  for  the  cure  of 
which  ligation  of  the  common  iliac  has  generally  been  done  are  less  likely 


384  LIGATION  OF 

to  impair  the  vitality  of  the  limb  than  are  the  aneurisms  for  which  ligation 
of  the  external  iliac  has  usually  been  undertaken? 

The  obliteration  by  any  method  of  ilio-femoral  aneurisms  giving  off  the 
deep  epigastric,  circumflex  iliac  and  profunda  arteries  might  well  be  fol- 
lowed by  impairment  more  or  less  serious  of  the  circulation  of  the  foot  and 
leg,  whereas  the  cure  of  an  aneurism  of  the  external  iliac  artery  terminating 
above  the  origin  of  one  or  more  of  these  branches  should  not  be  attended 
with  equal  consequence. 

As  shown  by  Porta,25  Pirogoff 2'  and  Kast,30  and  as  observed  by  myself, 
the  epigastric  and  circumflex  arteries  are  of  great  importance  in  the  estab- 
lishment of  the  collateral  circulation  after  ligation  of  the  abdominal  aorta. 
Salomon  and  Czerny  have  emphasized  the  great  dilatation  of  the  internal 
iliac  and  its  branches  after  ligation  of  the  common  iliac  artery.  The  anas- 
tomoses between  the  two  internal  iliacs  are  very  free  and  numerous,  and 
through  these  the  blood  reaches  the  femoral  artery  chiefly  by  way  of  the  pro- 
funda. I  have  already  called  attention  to  the  interesting  fact  that  in 
Kiimmel's  case  (Table  A,  No.  5)  the  circulation  of  the  limb  remained  good 
until  the  profunda  and  its  circumflex  branches  were  occluded,  although  the 
common  iliac,  the  external  iliac  (twice)  and  the  femoral  (three  times)  had 
previously  been  ligated. 

We  find  additional  demonstration  of  the  importance  of  the  anastomoses 
between  the  internal  iliac  arteries  of  the  two  sides  after  ligation  of  the 
common  iliac  in  the  two  cases  of  our  collection  in  which  the  sac  of  an 
aneurism  in  the  gluteal  region  was  excised.  In  both  of  these  gangrene 
supervened. 

Ligation  in  continuity  should  rarely  be  resorted  to,  for  when  branches 
are  given  off  between  the  sac  and  the  ligature,  the  circulation  of  the  limb 
is  more  impaired  than  by  ligation,  tangential  to  the  sac,  and  for  the  reason 
that  the  artery  becomes  obstructed  in  two  places,  at  the  site  of  the  ligation 
and  of  the  aneurism. 

Paetial  Occlusion 

It  may  be  asked,  "  What  is  to  be  gained  by  partial  occlusion  of  the  com- 
mon iliac,  if  its  object  is  the  cure  of  the  aneurism  and  obliteration  of  the 
arteries  given  off  from  the  sac  ?  "  The  reply  is  that  with  the  partial  occlu- 
sion of  the  parent  trunk,  the  direct  circulation  through  the  internal  iliac 

"Delia  Alterazioni  Patologiche  Delia  Arterie  Per  La  Ligatura  E  La  Torsione. 
Esperienze  Ed  Osservazioni  Di  Liugi  Porta.   Milano,  1845. 

"PirogofT.  Journal  der  Chirurgie  und  Augenheilkunde.  v.  Walter  und  v.  Griife, 
1838,  xxvii. 

*°Kast,  Deutsche  Zeitsch.  f.  Chirurgie,  xii,  405. 


COMMON  ILIAC  ARTEEY  385 

is  not  obturated.  I  believe,,  however,  that  the  common  iliac  artery,  partially 
occluded  by  a  metal  band,  will  ultimately  become  completely  obstructed. 
My  experiments  on  the  aorta  of  dogs  afford  ample  proof  for  the  belief  that 
even  a  small  direct  stream  is  of  great  value.  Thus  a  considerable  mortality 
attended  the  complete  occlusion  of  the  aorta  in  dogs,  whereas  with  partial 
obstruction  by  the  metal  band,  death  rarely  occurred.  In  man,  I  have  in 
four  instances  had  the  opportunity  to  observe  the  effect  of  partial  occlusion 
of  the  aorta.  In  no  case  were  disquieting  symptoms  manifested,  although 
in  one  patient  the  femoral  pulse  was  obliterated  by  the  partial  obstruction 
and  reappeared  only  on  agitation  or  exertion. 

These  results  are  in  striking  contrast  with  those  consequent  to  ligation 
of  the  aorta. 

A  fusiform  aneurism  of  the  aorta  was  so  greatly  reduced  in  size  by  par- 
tial occlusion  with  the  metal  band  that  relief  from  the  symptoms  was 
obtained  and  the  aneurism  was  believed  to  have  been  almost  cured.  But 
the  patient  died  in  six  weeks  from  a  sudden  haemorrhage  due  probably  to 
atrophy  of  the  diseased  arterial  wall  and  the  cutting  through  of  the  band. 

A  band  was  applied  one  and  a  half  years  ago  to  a  greatly  dilated  vein 
proximal  to  an  arterio-venous  fistula,  which  had  been  painstakingly  explored 
in  the  hope  that  the  opening  might  be  closed  without  obliteration  of  either 
the  vein  or  the  artery.  The  patient,  an  old  man,  with  advanced  arterio- 
sclerosis, has  recently  sent  me  word  by  his  physician,  Dr.  Fox  of  Greenville, 
Tenn.,  that  his  condition  is  greatly  improved  by  the  operation. 

The  partially  occluding  metal  band  has  already  been  applied  by  me  in 
man  to  all  of  the  principal  arteries,  to  the  aorta  four  times;  innominate, 
once;  subclavian,  twice;  carotid,  many  times;  femoral,  three  times;  pop- 
liteal, once;  and  without  accident  except  in  the  aortic  case,  referred  to 
above,  which  will  probably  be  reported  later  by  the  eminent  director  of  a 
European  clinic. 

The  partial  occlusion,  with  a  metal  band,  of  an  artery,  other  than  the  aorta 
must,  ultimately,  it  seems  to  me,  bring  about  total  obliteration  of  its  lumen. 
Occasionally  the  aorta  becomes  converted,  under  the  band,  into  a  solid 
fibrous  cord.  This  has  occurred,  thus  far  only  in  cases  in  which  the  vessel 
was  almost  completely  occluded. 

But  I  have  been  constantly  apprehensive  lest,  in  the  case  of  the  aorta,  the 
wall  might  ultimately  give  way,  atrophying  slowly  but  surely,  under  the 
pressure  exerted  by  the  constricting  metal.  As  our  laboratory  for  experi- 
mental surgery  is  closed  during  the  summer,  it  has  not  been  feasible  for  me 
to  observe  the  ultimate  effect  of  a  partially  occluding  band  upon  the  aorta 
for  a  period  longer  than  7£  months.  In  many  instances,  however,  I  have 
noted  a  thinning  of  the  aortic  wall  under  the  band,  and  in  some  the  attenua- 
26 


386  LIGATION  OF 

tion  has  been  so  great  that  I  could  foresee  no  outcome  other  than  perforation 
of  the  wall  of  the  artery. 

In  total  occlusion  of  the  artery  the  band  in  three  animals  was  found 
embedded  in  a  strong,  fibrous  capsule  continuous  above  and  below  with  the 
arterial  wall.  In  this  manner  haemorrhage  was  prevented,  notwithstanding 
the  fact  that  the  aorta  as  well  as  the  fibrous  capsule  were  patulous  through- 
out. The  band  was,  however,  so  snugly  embraced  by  the  surrounding  cylin- 
der of  fibrous  tissue  that  little,  if  any,  blood  could  pass  between  the  two. 

But  in  the  cases  of  partial  occlusion  of  the  aorta  no  such  fibrous  capsule 
was  forming,  and  for  the  reason,  undoubtedly,  that  there  was  no  occasion 
for  its  formation.  The  occasion  would,  probably,  come  sooner  or  later,  and 
perhaps,  altogether  without  warning,  or  too  quickly  for  efficient  response 
from  the  surrounding  tissues. 

Hence,  if  a  partially  obstructing  metal  band  is  applied  to  the  aorta,  it 
would  seem  that  some  further  operative  procedure  must  usually  be  con- 
templated, even  if  the  aneurism  should  be  apparently  cured.  It  might  con- 
sist in  partial  occlusion  of  both  common  iliac  arteries  (this  might  be  done 
as  part  of  the  original  operation)  and  later  of  complete  occlusion  of  the 
aorta,  by  bands  or  possibly  ligatures,  both  above  and  below  the  original  band. 
In  the  cases  in  which  it  may  be  ventured  to  close  the  aorta  almost  com- 
pletely, the  fibrous-cord  formation  might  be  hoped  for,  and  the  omission  of 
a  second  operation  justified. 

We  noted  further  in  our  experiments  that  the  aorta  of  dogs  after  having 
been  totally  occluded  by  silk  ligature  may  again  become  patulous.  This 
restoration  of  lumen  is  brought  about  by  the  cutting  through  of  the  ligature, 
and  has  usually  been  accompanied  by  the  formation  of  a  diaphragm  of 
greater  or  less  extent.31  Similar  observations  have  been  made  upon  the  human 
subject  after  the  ligation  of  large  arteries  (innominate,  subclavian,  femoral). 

Acting  on  this  hint  given  by  nature,  I  tested,  last  winter,  on  thirteen  dogs, 
the  effect  of  partially  occluding  ligatures  of  fine  silk,  placed  one  above  the 
other  on  the  aorta,  hoping  that  we  might  obtain  a  series  of  superimposed 
diaphragms  which,  if  sufficient  in  number  and  extent,  might  sufficiently 
obturate  the  aorta  to  bring  about  the  cure  of  an  aneurism. 

But  these  partially  occluding  ligatures  of  very  fine  silk,  not  only  produced 
no  diaphragms,  but  gave  rise  in  two  of  the  thirteen  dogs  to  fatal  haemorrhage. 

From  the  totally  occluding,  crushing,  coarse,  silk  ligature  in  dogs,  I  have 
seen  no  case  of  haemorrhage.  Was,  then,  the  fineness  of  the  silk  or  the  incom- 
pleteness of  the  occlusion  responsible  for  the  bleeding?  Or  were  both  con- 
cerned in  bringing  about  the  result  ? 

"  Jour,  of  Exp.  Med.,  1909,  vol.  xi,  no.  1. 


COMMON  ILIAC  AETEEY  387 

We  are  now  testing  the  behavior  of  organizable  tissues  used  as  bands  to 
constrict  the  aorta.  Spiral  strips  and  cuffs  cut  from  the  fresh  aorta  of  one 
dog  are  wound  about  the  aorta  of  others.  I  should  fear,  however,  that  tissues 
capable  of  organization  under  such  circumstances  would  be  stretched  *  by 
the  dilating  force  of  the  aortic  pulse.  Should  they  serve  their  purpose  for 
a  time,  enough  might  possibly  be  accomplished  to  enable  one  at  a  subsequent 
operation  to  produce,  if  necessary,  complete  occlusion  in  some  other  way. 

"June  3,  1912.  Since  going  to  press  one  of  two  dogs  operated  upon  Apirl  29  for 
the  purpose  of  testing  the  effect  of  cuffs  and  of  spiral  strips  of  the  fresh  aorta  of  one 
dog  wound  about  and  constricting  the  aorta  of  others  we  examined  today  under 
ether,  and  to  our  delight  and  surprise  found  that  the  aortic  cuff  which  had  been 
used  in  this  experiment  seemed  to  be  completely  organized  and  had  not,  apparently, 
stretched  in  the  least.  The  aortic  pulse  immediately  above  the  constricting  cuff 
was  forcible;  just  below  the  cuff  it  was  feeble  but  countable,  and  at  this  point 
a  barely  perceptible  thrill  was  appreciable.  The  left  femoral  pulse  could  with 
difficulty  be  felt  and  counted  by  Dr.  Goetsch  who  with  Dr.  Jacobson  assisted  me  in 
making  the  examination,  but  on  the  right  side  (smaller  artery)  it  was  questionable 
whether  or  not  the  pulse  could  be  appreciated  with  the  finger.  Having  clamped  all 
the  aortic  branches  up  to  the  band,  it  was  noted  on  removal  of  the  clamp  from  one 
of  the  common  iliac  arteries  that  the  blood  trickled  feebly  and  with  barely  per- 
ceptible pulsation  from  the  open  end  of  the  vessel.  On  dissecting  the  aorta  after 
removal  from  the  body,  it  was  ascertained  that  the  cuff  which  seemed,  as  it  were, 
welded  to  it  had  not  stretched  or  become  thinned  or  altered  in  appearance.  A  fine 
probe  passed  into  the  aorta  was  snugly  embraced  at  the  site  of  the  cuff.  The  artery 
was  split  open  at  both  ends  up  to  the  cuff  and  the  fine  opening  and  characteristic 
wrinkling  of  the  constricted  vessel  noted.  There  was  almost  no  reaction  about  the 
cuff  which  seemed  to  be  organized.  Even  its  free  flaps  had  retained  their  original 
dimensions. 

Another  dog,  operated  upon  on  the  same  day  and  in  the  same  manner,  except 
that  a  spiral  strip  of  aorta  instead  of  a  cuff  was  used  for  the  band,  died  suddenly 
about  three  weeks  after  the  operation.  In  this  instance  the  aorta  had  been  almost 
completely  occluded  by  the  spiral  band  the  turns  of  which  had  been  held  by  three 
fine  silk  sutures,  two  applied  at  the  pointed  ends  of  the  spiral  strip  and  one  near 
its  middle.  Dr.  Jacobson,  who  kindly  took  charge  of  the  dogs  after  operation,  re- 
moved the  specimen  which  I  have  just  examined.  The  findings  are  precisely  the 
same  as  in  the  first  case.  The  weld-like  band  had  not  stretched,  ana  the  aorta,  on 
being  split  longitudinally,  was  seen  to  be  greatly  wrinkled  and  almost  occluded  at 
the  site  of  the  seemingly  organized  spiral  strip.  There  was  no  adhesion  between 
the  folded  intimal  surfaces  which  had  been  so  firmly  held  in  contact. 

Thus,  perhaps,  at  last,  a  safe  and  reliable  method  for  occluding  the  aorta  has  been 
found,  and  an  interesting  and  promising  field  for  investigation  opened. 

Fresh  tissues  of  other  kind  may  serve  the  purpose  quite  as  well  as  the  aortic  cuffs 
or  strips.  This  remains  to  be  determined.  We  await  the  findings  of  the  histological 
examination  of  the  specimens  with  much  interest. 

In  similar  manner,  with  band  of  fresh  tissue,  partial  and  complete  obstruction 
and  isolation  of  the  intestine  might  be  produced. 


388  LIGATION  OF 

Lateral  excision  of  a  piece  of  the  aortic  wall  and  suture  of  the  defect 
might  easily  be  accomplished  experimentally,  but  in  the  presence  of  aneu- 
rism this  would,  I  fear,  rarely  be  feasible ;  for  the  aneurism  usually  occupies 
so  much  space  that  there  is  not  sufficient  room  above  it,  for  example,  between 
it  and  the  renal  arteries,  for  the  carrying  out  of  any  such  measure.  Ordinarily 
it  would  be  difficult  to  obtain  more  than  room  enough  for  the  application 
of  a  band. 

Function 

Unfortunately  there  are  not  sufficient  data  to  enable  me  to  formulate  con- 
clusions as  to  the  ultimate  usefulness  of  the  limb  after  ligation  of  the 
common  iliac. 

In  Table  C  is  embodied  all  that  we  have  learned  in  one  hundred  years 
concerning  the  function  of  the  limb  following  this  operation. 

Seven  of  the  thirty-two  cases  tabulated  by  Stephen  Smith  recovered. 
One  of  these  (Guthrie)  belongs  to  Group  III.  Of  the  remaining  six  cases, 
one  (Deguise)  is  in  Group  I,  five  (Mott,  Salomon,  Peace,  Hey,  Garviso) 
are  in  Group  II. 

Deguise's  patient  left  the  hospital  in  five  weeks.  There  is  no  note  of  sub- 
sequent observation.  For  the  study  of  function  this  case  might  be  con- 
sidered under  Group  II,  for  the  operation  which  resulted  in  the  ligation  of 
the  common  iliac  was  undertaken  for  the  cure  of  an  inguinal  aneurism.  It 
was  only  in  the  course  of  the  operation  that  haemorrhage  necessitating  the 
ligation  of  the  common  iliac  occurred.  (Vid.  Am.  Jour.  Med.  Sc,  Oct., 
1841,  p.  475.)  If  this  case  were  transferred  to  Group  II,  the  mortality  for 
ligation  of  the  common  iliac  prior  to  1860  would  be  100  instead  of  91 
per  cent. 

Mott's  patient,  observed  3£  months,  stated  at  the  end  of  this  period  that 
his  leg  was  as  strong  as  the  other.  While  the  memories  of  the  agonizing 
pains  suffered  before  the  operation  were  still  vivid,  it  is  supposable  that  he 
might  in  his  joy  at  being  relieved  of  his  torture  and  in  his  desire  to  empha- 
size his  gratitude  to  his  deliverer  have  overestimated  the  relative  usefulness 
of  the  limb. 

It  will  be  observed  that  my  patient,  operated  upon  three  and  a  half  years 
ago,  wrote  enthusiastically  of  the  result  a  year  after  being  cured,  but  now 
realizes  that  he  is  considerably  incapacitated.  Salomon's  patient  died  ten 
months  after  the  operation  from  a  suppurative  inflammation  in  the  course 
of  the  psoas  muscle  on  the  affected  side.  It  is  stated  that  the  patient  of 
Peace  was  able  to  provide  for  his  family,  pursuing  the  arduous  occupation 
of  loading  boats  with  stones.  But  about  14  months  after  the  operation, 
a  small,  soft,  non-pulsating  tumor  appeared  at  the  site  of  the  aneurism. 


COMMOX  ILIAC  ARTERY 


389 


.5     «    - 

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00       00       00 


00       CS       O       C5       O       CS       O 


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CS       «       »H       N 


390  LIGATION  OF 

Perforation  of  the  skin  and  haemorrhage  took  place  in  a  few  days,  and  in 
eleven  days  thereafter  he  died. 

Nothing  is  known  of  the  cases  of  Hey  and  Garviso  after  leaving  the 
hospital. 

Kiimmel  adds  to  Smith's  list  two  cases  of  cure  between  1860  and  1880 
(McKinlay's,  Group  I,  and  Cock's,  Group  II). 

McKinlay's  case  is  not  pertinent  for  the  study  of  function,  for  the  thigh 
was  amputated.  In  Cock's  case  there  is  a  note  that  when  seen  "  a  few  months 
after  leaving  the  hospital  there  were  no  untoward  symptoms,"  and  that  he 
resumed  his  occupation. 

Hence  for  the  septic  period  only  one  case  (Peace,  14  months)  was  observed 
long  enough  to  be  considered  in  estimating  the  usefulness  of  the  limb. 

Of  the  thirty  cases  of  the  antiseptic  period,  fourteen  died.  Of  the  remain- 
ing sixteen,  seven  had  gangrene.  Of  the  nine  without  gangrene  (and  these, 
of  course,  are  the  only  ones  to  be  considered  under  the  heading  of  function) 
there  is  in  two  (Lucas  and  Stevenson)  no  record  of  observation  after  the 
discharge  from  the  hospital.  In  one  (Kiister)  the  operation  was  performed 
on  a  patient  incapacitated  by  elephantiasis.  Of  the  others,  Beckman's  was 
observed  for  two  months  ("improved"),  Martin's  for  two  and  one-third 
months  ("could  walk  about  slowly"),  McBurney's  for  three  months 
("weakness  in  left  leg"). 

At  the  end  of  six  months,  Jameson's  patient  walked  with  difficulty.  The 
hip  and  knee  were  flexed. 

Clark's  patient,  observed  for  nine  months,  worked  as  a  porter,  wheeling 
a  barrow  about  a  railroad  station. 

My  patient  is  still  under  observation,  three  and  one-quarter  years  since 
the  operation.   April  4,  1912,  he  wrote  me: 

"  My  left  leg  is  a  great  deal  weaker  than  my  right.  I  can't  walk  very 
much  as  I  have  pain  in  my  left  leg  when  I  do  any  walking  and  in  case  it 
gets  very  cold.  My  present  weight  is  180  pounds.  I  have  a  splendid  appe- 
tite and  haven't  been  ill  since  my  return.  All  traces  of  the  aneurism  have 
disappeared  and  it  never  worries  me  the  least  bit." 

Mortality 

Stephen  Smith  in  reviewing  the  result  in  the  cases  of  his  first  group 
writes : 

"Of  11  cases,  10  were  fatal,  one  recovered,  being  a  mortality  of  nearly 
91  per  cent.  The  success  of  this  operation  upon  the  primitive  iliac  artery 
for  the  causes  above  assigned,  presents  a  striking  contrast  with  the  operation 
upon  the  external  iliac  for  the  same  class  of  diseases  and  accidents.  Of  14 
cases  of  deligation  of  the  external  iliac  artery  for  the  arrest  of  haemorrhage, 
I  find  that  11  were  successful  and  three  fatal,  the  mortality  being  about 
21J  per  cent." 


COMMON  ILIAC  ARTERY 


391 


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392  LIGATION  OF 

Concerning  Group  II,  he  remarks : 

"  A  just  appreciation  of  the  results  of  these  15  cases  would  give  the  fol- 
lowing conclusions:  recoveries,  five;  permanently  cured,  one  (Mott) ;  tem- 
porarily, two  (Salomon,  Peace) ;  unknown,  two  (Hey,  Garviso)  ;  died,  ten; 
fault  of  ligature,  one  (Crampton) ;  condition  of  patient  most  unfavorable  at 
time  of  operation,  two  (Syme,  Van  Buren)  ;  intercurrent  disease  uncon- 
nected with  operation,  one  (Stone)  ;  connected  with  operation,  three 
(Stevens,  Jones,  Wedderburn)  ;  local  disease  due  to  operation,  one  (Stephen 
Smith) ;  cause  of  sinking  and  death  uncertain,  one  (Goldsmith)  ;  attributed 
to  operation,  one  (Lyon). 

"  The  results  of  the  operation  of  deligation  of  the  common  iliac  artery 
for  aneurism,  as  compared  with  the  same  operation  upon  the  external  iliac, 
is  worthy  of  notice.  In  95  cases,  which  I  have  examined,  of  ligation  of  the 
latter  artery  for  aneurism,  69  recovered  and  26  died,  being  a  mortality  of 
about  27  per  cent,  or  less  than  half  the  mortality  of  the  same  operation  for 
the  same  disease  when  performed  upon  the  common  trunk.  The  cause  of 
death  in  11  cases,  or  nearly  one-half,  of  ligation  of  the  external  iliac  for 
aneurism  was  mortification  of  the  limb,  presenting  a  striking  contrast  with 
the  same  operation  upon  the  primitive  iliac,  in  which  there  was  but  one 
instance  in  eight  cases." 

Dreist  collected  52  cases  from  the  septic  era;  17  of  these  are  in  Group  I; 
14  died;  mortality  82.35  per  cent;  35  are  in  Group  II;  26  died;  mortality 
74.29  per  cent.  From  the  antiseptic  era  (since  1880)  he  collected  10  cases; 
five  in  Group  I,  with  three  deaths ;  mortality  60  per  cent ;  five  in  Group  II, 
with  three  deaths;  mortality  60  per  cent. 

I  have  compiled  for  the  hundred  years  from  1812  to  1912  (Groups  I 
and  II)  76  cases  of  ligation  of  the  common  iliac.  Hence  three-quarters  of 
a  case  per  year  since  the  first  ligation  by  Gibson.  Forty-six  of  these  were 
operated  upon  prior  to  1880  (septic  era) ;  30  subsequent  to  that  year. 

Sixteen  are  in  Group  I;  of  these  three  recovered;  mortality,  81.3  per  cent. 
Sixty  are  in  Group  II ;  recovered,  25 ;  mortality,  58.4  per  cent.  Of  the  30 
cases,  Group  II,  of  the  septic  period,  21  died;  mortality  70  per  cent.  Of  the 
30  cases,  Group  II,  of  the  antiseptic  period,  14  died;  mortality,  46.6  per  cent. 

Analysing  the  14  fatalities  since  1880  (vid.  Table  D),  we  find  that  in 
three  cases  only  (Fluhrer,  Bryant  and  Judd)  could  death  be  attributed 
solely  to  the  ligation  of  the  common  iliac  artery.  In  all  the  others  there  were 
serious  complications,  sufficient  to  account  for  the  fatal  termination.  In 
Fluhrer's  patient  nephritis  is  given  as  the  cause  of  death.  In  Bryant's,  no 
cause  is  assigned ;  the  report,  however,  is  very  brief.  Judd's  patient  did  not 
rally  from  the  shock  of  the  prolonged  (three  hours)  operation.  The  mor- 
tality, therefore,  in  the  uncomplicated  cases  is  at  most  10  per  cent.  Possibly 
it  is  only  3.3  per  cent. 


COMMON  ILIAC  ARTERY  393 

Epiceisis. 

From  the  critical  consideration  of  the  cases  collated  in  this  paper  we  may, 
I  think,  conclude  that  the  uncomplicated  ligation  of  the  common  iliac  artery 
is  not  likely  to  be  followed  by  gangrene,  the  percentage  being  from  3.3  to 
6.6  instead  of  33.3 ;  and  that  the  mortality,  contrasted  with  60  per  cent  as 
estimated  by  Dreist  for  Groups  I  and  II,  is  at  most  10  per  cent  and  prob- 
ably not  more  than  6.6  per  cent ;  or  it  may  even  be  as  low  as  3.3  per  cent. 

The  data  are  too  meagre  to  justify  an  expression  of  opinion  as  to  func- 
tion, my  patient  being  the  only  one  observed  for  sufficient  time.  In  this 
man,  although  there  may  be  no  visible  signs  of  disturbed  circulation,  the 
fact  that  he  is  unable  to  walk  further  than  a  very  short  distance  without 
cramp-like  pain  would  seem  to  indicate  that  the  impairment  of  function 
should  be  attributed  to  ischaemia  of  the  limb. 

In  Clark's  case,  at  nine  months,  the  function  seems  to  have  been  good. 
His  patient  was  only  26  years  old. 

Notwithstanding  the  low  mortality  and  the  infrequency  of  gangrene  con- 
sequent upon  ligation  of  the  common  iliac  for  aneurism,  the  operation  is  not 
an  ideal  surgical  procedure,  and  chiefly,  in  my  opinion,  for  the  reason  that 
it  cuts  off  the  direct  blood  supply  from  the  internal  iliac. 

Furthermore,  the  operation  under  consideration  does  not  invariably 
cure  aneurism.  In  the  eleven  cases  of  recovery  5  since  1880,  without  gan- 
grene, and  in  which  the  operation  was  performed  for  aneurism,  there  was 
recurrence  in  one  after  seven  months  (Gillette),  and  of  the  six  cases  in 
Stephen  Smith's  collection,  one  recurred  after  fourteen  months  (Peace).  It 
is  possible  that  in  other  cases,  also,  recurrence  would  have  been  noted  had 
the  patients  been  observed  for  a  longer  period. 

In  extirpation  of  the  aneurism  we  have  a  means  of  curing  it.  But  that 
this  procedure,  which  has  rarely  been  resorted  to  in  the  case  of  aneurism 
of  the  external  iliac  artery  is  less  dangerous,  or  less  or  more  liable  to  be 
followed  by  gangrene,  we  do  not  as  yet  know.  "We  might,  however,  predict 
that  the  function  of  the  limb  would  be  less  impaired  by  the  excision  of  the 
sac  than  by  the  ligation  of  the  common  iliac,  because  the  former  operation 
does  not  interrupt  the  circulation  in  the  internal  iliac  artery. 

In  the  excision  of  such  an  aneurism  the  external  iliac  would  have  to  be 
ligated  twice  and  if  the  lower  ligature  had  to  be  placed  below  the  deep 
epigastric  and  circumflex  iliac  arteries,  the  limb  would  be  deprived  of  the 
services  of  these  important  anastomotic  channels.  "We  know,  as  I  have  said, 
but  only  in  a  general  way,  that  ligation  of  the  external  iliac  is  much  more 


394  LIGATION  OF 

likely  to  be  followed  by  gangrene  than  is  ligation  of  the  primitive  stem.33 
Furthermore,  the  enucleation  of  an  aneurism  may  be  difficult  and  attended 
with  the  danger  of  wounding  important  veins  and  of  thrombosis  of  vessels 
not  actually  cut  or  torn. 

The  ideal  operation,  as  it  seems  to  us  at  present,  is  one  which  causes  only 
so  much  disturbance  of  the  circulation  as  is  necessarily  incident  to  a  spon- 
taneous cure  of  the  aneurism,  namely  its  obliteration. 

This  is  precisely  what  the  Matas  operation  contemplates.  The  vessels 
which  are  given  off  from  the  sac  must,  in  the  course  of  cure,  be  occluded  at 
their  origin,  and,  presumably,  to  the  first  collateral  branch. 

I  should  suppose,  however,  that  the  danger  of  gangrene  after  the  Matas 
operation  would  be  at  least  as  great  as  from  ligation  of  the  afferent  artery 
immediately  above  the  aneurism,  were  it  not  that  the  former  procedure 
promptly  relieves  the  patient  of  the  tumor  and  the  pressure  which  it  exerts, 
whereas  after  ligation  many  months  may  be  required  for  the  absorption 
of  the  aneurism.  Also  in  favor  of  undertaking  to  perform  the  Matas  opera- 
tion, even  in  cases  which  might  prove  to  be  unsuitable  for  it,  is  the  fact  that 
the  precise  state  of  affairs  becomes  investigated  and  such  endeavor  not 
infrequently  may  result  in  the  finding  of  a  hole  in  the  artery,  as  in  the  case 
of  Balch  and  Murphy,34  the  closure  of  which  will  suffice  to  cure  the  spurious 
aneurism.  In  such  case,  although  the  performance  of  the  Matas  operation 
is  not  indicated  and,  indeed,  not  possible,  the  result  will  justify  the  means. 

In  other  words,  the  condition  of  the  patient  permitting,  a  thorough  opera- 
tive investigation  should  be  made  in  all  cases  of  aneurism  or  wound  of  the 
external  iliac  artery. 

A  fatal  termination  might  have  been  avoided  in  a  very  considerable  num- 
ber of  the  cases  of  ligation  of  the  common  iliac  if  this  vessel  had  been 
temporarily  compressed  and  the  precise  condition  investigated  at  the  first 
operation. 

I  should  not  suppose  that  the  preservation  of  the  vaso  vasorum  would  be 
important  for  the  prevention  of  gangrene  which,  when  it  occurs,  follows 
operation  too  quickly  for  these  little  vessels  to  have  become  serviceable. 
Maintenance  of  their  integrity  might  possibly  be  of  value  for  the  preserva- 
tion of  function. 

In  what  has  been  said,  I  have  not  had  in  mind  either  the  restorative  or 
reconstructive  operations  of  this  eminent  surgeon.  The  former  of  these 
procedures  may  have  a  sphere  of  great  usefulness  in  saccular  and  arterio- 

"  It  would  be  interesting  to  try  to  determine  by  careful  study  of  the  cases,  the 
explanation  of  this  well  established  fact.  It  is  my  opinion,  as  already  indicated, 
that  it  may  be  found  in  the  situation  of  the  aneurism. 

M  Boston  Med.  &  Surg.  Jour,  1908,  Dec.  24,  p.  860. 


COMMON"  ILIAC  AETEKY  395 

venous  aneurisms,  but  I  have  not  regarded  with  much  favor  the  attempts 
which  have  been  made  to  reconstruct  arteries  from  the  diseased  wall  of  the 
aneurism.  I  believe  it  will  be  found  that  modification  of  the  Matas  opera- 
tion may  be  indicated  in  many  cases,  possibly  in  a  considerable  proportion 
of  them.  It  may,  for  example,  not  always  be  desirable,  even  when  possible, 
to  approximate  the  intimal  surface  throughout.  In  some  cases  it  may  seem 
better  to  split  the  sac  longitudinally  or  otherwise,  in  one  or  more  places,  and 
to  close  the  several  parts  of  the  sac  independently.  In  others  the  sac  may 
lend  itself  in  part  or  in  toto  to  excision  naturally  and  without  injury  to 
outside  vessels,  and  when  this  is  the  case  enough  of  the  sac  might  be  left  on 
the  stump  of  the  various  arteries  to  enable  the  surgeon  to  close  their  orifices, 
from  the  intimal  side,  if  it  should  seem  advisable  to  do  so,  with  one  or  more 
circular  stitches  or  rows  of  suture. 

In  cases  in  which  no  advantage  is  to  be  gained  by  leaving  the  sac,  it  might, 
perhaps,  better  be  removed.  It  should,  in  my  opinion,  never  be  drained 
merely  for  the  sake  of  drainage.  It  is  conceivable  that  in  rare  instances  it 
might  have  to  be  packed  for  the  control  of  haemorrhage,  as,  for  example, 
in  a  case  of  spurious  aneurism,  when,  if  the  patient  were  exhausted,  it  might 
be  unwise  to  attempt  to  check  every  oozing  point. 

In  the  case  of  subclavian  aneurisms  I  am  still  of  the  opinion  that  excision 
when  feasible  may  prove  ultimately  to  be  the  best  treatment  in  selected  cases. 
When  the  sac  lends  itself  easily  to  enucleation  without  danger  to  the  con- 
tiguous vessels,  there  should  be  no  added  danger  attending  its  extirpation. 
All  of  the  arteries  arising  from  it  can  be  ligated  as  they  present  themselves 
in  the  course  of  the  dissection — arteries  which  in  the  performance  of  the 
Matas  operation  would  either  have  to  be  exposed  and  temporarily  clamped, 
or  occluded,  less  advantageously  perhaps,  and  at  times  with  difficulty  in  the 
presence  of  haemorrhage,  from  within  the  sac.  In  many  instances  the  opera- 
tors have  been  greatly  embarrassed  on  opening  the  sac  by  haemorrhage  from 
vessels  which  were  not  or  could  not  be  clamped  from  without. 

Of  the  cases  not  located  on  the  extremities,  those  lend  themselves  best 
to  the  performance  of  the  Matas  operation  in  which  all  of  the  arteries  lead- 
ing from  the  sac  can  be  temporarily  clamped  outside  of  it.  Now  when  all 
of  these  have  been  exposed  sufficiently  for  clamping  it  is  not  quite  clear 
to  me  why  their  permanent  closure  should  be  deferred  until  the  sac  shall 
have  been  opened. 

A  few  days  ago,  in  operating  upon  an  aneurism  of  the  dorsalis  pedis 
artery,  the  afferent  and  efferent  orifices  were  less  than  1  cm.  apart  and  were 
easily  approximated  without  tension.  An  end-to-end  suture  which  in  some 
situations  and  under  certain  conditions  would  be  unquestionably  indicated 


396  LIGATION  OF 

was  not  considered  worth  while,  and  it  would  have  seemed  absurd  not  to 
have  excised  the  readily  enucleable  sac. 

Each  aneurism  presents  its  special  problems  which  it  may  not  be  possible 
to  solve  altogether  until  the  operation  has  neared  completion. 

As  a  general  proposition,  I  should  be  disposed  to  ligate  permanently, 
just  outside  of  the  sac,  all  arteries  which  in  the  natural  course  of  perform- 
ance of  the  Matas  operation  would  be  clamped  temporarily.  And,  inasmuch 
as  all  arteries  leading  from  the  sac  should,  when  feasible,  be  under  the  con- 
trol of  clamps  (when  not  controllable  by  the  elastic  bandage)  before  the  sac 
is  opened,  are  there  good  reasons  for  not  removing  under  these  circumstances 
a  sac  which  has,  in  the  process  of  the  exposure  of  the  arteries  for  clamping, 
become  almost  enucleated? 

I  have  been  unable  as  yet  to  convince  myself  that  arteries  which  have 
been  temporarily  occluded  in  close  proximity  to  the  aneurism  might  not 
better  be  tied  at  once  and  divided,  for  thus  the  arteries  still  to  be  sought 
with  the  object  of  temporary  occlusion  in  view  become  more  readily  accessi- 
ble. And  when  these  secondary  arteries  have  been  clamped  why  not  ligate 
and  divide  them  also  for  the  same  reason,  and  so  on  until  all  of  the  arteries, 
which  in  the  course  of  the  Matas  operation  would  be  temporarily  occluded, 
have  been  tied  off? 

So  much  of  the  sac  as,  by  this  time,  may  have  been  dissected  out,  might, 
it  seems  to  me,  be  removed  with  advantage  unless  it  could  serve  some  special 
purpose  by  being  left. 

And  even  in  the  cases  in  which  the  Matas  operation  seems  to  be  clearly 
indicated  and  in  which  temporary  compression  of  the  main  artery  above  and 
below  the  sac  is  contemplated,  the  dissection  necessary  for  an  exposure  of 
this  vessel  which  would  be  ample  for  the  simple  ligation  might  be  insuffi- 
cient for  its  temporary  occlusion  with  the  necessarily  somewhat  cumbersome 
clamps  designed  therefor. 

In  the  case  of  popliteal  aneurisms  especially,  and  of  aneurisms  so  situated 
that  their  blood  supply  can  be  completely  controlled  by  tourniquet  the  Matas 
operation  plays  an  important  role.  In  brief  it  is  particularly  applicable  to 
the  treatment  of  such  aneurisms  of  the  extremities  the  extirpation  of  which 
might  be  attended  with  greater  interference  with  the  circulation.  In  other 
situations,  in  the  case  of  easily  enucleable  aneurisms,  the  danger  of  haemor- 
rhage should  ordinarily  be  less  with  extirpation  than  with  the  Matas 
operation. 

Dr.  Matas  has  with  great  courtesy  written  me  concerning  the  cases  of 
aneurism  of  the  external  iliac  and  ilio-femoral  arteries  which  have  been 
treated  by  his  method  and  I  await  with  interest  their  publication  in  detail. 
No  one,  I  am  sure,  can  be  more  eager  than  he  to  determine  the  precise  indi- 


COMMON  ILIAC  ARTERY  397 

cations  for  the  operation  so  brilliantly  conceived  by  him  or  to  suggest  modi- 
fications of  it  should  they  seem  to  be  clearly  indicated. 

It  is  undoubtedly  the  duty  of  every  surgeon  to  familiarize  himself  by 
much  practice  on  animals  with  the  treatment  of  wounds  of  the  heart  and 
largest  blood  vessels,  vein  and  arteries,  for  otherwise  he  might  be  unable 
to  cope  properly  with  an  emergency  which,  any  day,  may  confront  the  active 
practitioner  of  this  art.  I  would  recommend  the  making  of  fistulae  between 
the  aorta  and  vena  cava,  the  vena  cava  and  portal  vein,  and  between  the 
innominate  vessels.  Also  the  practice  of  the  end-to-end  suture  and  the 
implantation  of  vessels. 

One  of  the  chief  fascinations  of  surgery  is  the  management  of  wounded 
vessels,  the  avoidance  of  haemorrhage.  The  only  weapon  with  which  the 
unconscious  patient  can  immediately  retaliate  upon  the  incompetent  surgeon 
is  haemorrhage.  If  he  bleeds  to  death,  it  may  be  presumed  that  the  surgeon 
is  to  blame,  whereas  if  he  dies  of  infection,  or  shock,  or  from  an  unphysio- 
logical  operative  performance,  the  surgeon's  incompetence  may  not  be  so 
evident. 


A  CASE  OF  ILIO-FEMOEAL  ANEUEISM  EXEMPLIFYING  THE 
VALUE  OF  THE  PEELIMINAEY  PAETIAL  OCCLUSION  OF 
AN  AETEEY  IN  THE  TEEATMENT  OF  ANEUEISM1 

_  Excision  of  an  ilio-femoral  aneurism  three  weeks  after  preliminary  par- 
tial occlusion  of  the  external  iliac  artery. — Surgical  No.  31928.  W.  C, 
colored  man,  aged  40,  admitted  to  The  Johns  Hopkins  Hospital  April  10, 
1913.  Eleven  months  before  admission,  patient  noticed  a  dull  pain  on 
stooping  and  found  a  small,  pulsating  lump  in  the  left  groin  which  has 
steadily  increased  in  size.   Five  months  ago  the  limb  began  to  swell. 

Examination. — The  patient  is  a  tall,  muscular,  robust  negro.  The  thorax 
is  negative  except  for  a  systolic  blow  over  the  left  interscapular  region. 
Superficial  blood  vessels  are  sclerotic.  Blood  pressure  is  130.  The  abdomen 
is  distended;  there  are  tortuous  superficial  veins  over  left  abdomen,  and 
oedema  of  the  skin  to  the  level  of  the  twelfth  rib.  Over  the  aorta,  which 
seems  unusually  large,  a  distinct  bruit  is  heard.  The  left  leg  is  enormously 
swollen  from  groin  to  toe,  and  so  hard  that  even  on  forcible  pressure  there 
is  barely  a  suggestion  of  pitting.  The  entire  thigh  seems  to  throb  with  each 
pulsation,  and  the  skin  of  the  whole  extremity  is  very  much  darker  than  on 
the  opposite  side.  In  the  region  of  the  groin  is  a  great  pulsating  expansile 
swelling  which  extends  from  near  the  symphysis  pubis  to  the  anterior 
superior  spine  of  the  ilium,  and  from  a  line  joining  the  iliac  spines  of  the 
two  sides  to  a  point  about  10  cm.  below  Poupart's  ligament.  The  precise 
outlines  of  the  aneurism  cannot  be  determined,  on  account  of  the  great 
swelling  all  about  it,  except  above,  where  it  terminates  quite  abruptly. 
A  thrill  is  felt  over  the  tumor  and  a  bruit  can  be  heard  from  the  abdominal 
aorta  down  to  a  point  about  15  cm.  below  Poupart's  ligament. 

The  measurements  of  the  extremities  are  as  follows : 

Right  Left 

cm.  cm. 

Thigh  at  level  of  gluteal  fold 48.5  63 

Knee,    across    patella    33.5  45 

Calf   of  leg,   15  cm.  below  knee-joint    31.5  40.5 

Ankle,  2  cm.  above  internal   malleolus 20  26.5 

Believing  that  the  danger  of  gangrene  in  this  case  would  be  unusually 
great  either  from  ligation  of  the  external  iliac  artery,  from  excision  of  the 
sac,  or  from  the  Matas  endoaneurismorrhaphy,  indeed,  from  any  method 
which  would  suddenly  cure  the  aneurism,  except  possibly  vessel  transplan- 
tation, I  decided  to  make  a  preliminary  partial  occlusion  of  the  external 
iliac  artery. 

First  Operation. — Partial  occlusion  of  the  left  external  iliac  artery  with 
an  aluminum  band.   May  21,  1913 :   The  artery  was  readily  found.   It  was 

'J.  Am.  M.  Ass.,  Chicago,  1914,  lxiii,  207-208. 


ILIO-FEMOEAL  ANEUKISM  399 

abnormally  large,  very  deeply  situated  and  ran  from  behind  forward  instead 
of  from  above  downward.  The  vessel  was  freed  with  two  long  blunt  dis- 
sectors and  lifted  from  its  bed  with  two  tapes,  between  which  the  aluminum 
band  was  curled  about  it.  With  the  thumb  and  finger  the  band  was  rolled 
(tightened)  until  a  thrill  could  be  distinctly  felt  in  the  artery  below  it. 
The  band  was  again  rolled — tight  enough  this  time  to  obliterate  the  thrill 
in  the  artery  and  the  pulsation  in  the  aneurism.  A  very  faint,  hardly  per- 
ceptible pulse  could  still  be  felt  in  the  external  iliac  artery  between  the 
band  and  the  aneurism.  Thus  the  vessel  had  been  occluded  to  precisely  the 
desired  amount.  The  foot  immediately  became  quite  cold.  Had  the  artery 
been  totally  occluded  gangrene  might  have  resulted. 

After  closure  of  the  wound  a  faint  bruit,  now  confined  to  an  area  not 
over  4  cm.  in  diameter,  could  be  heard  just  below  Poupart's  ligament.  There 
was  no  appreciable  pulsation  in  the  aneurism. 

May  22d. —  (Twenty-four  hours  after  operation.)  Circulation  in  foot 
has  improved.  Patient  can  move  toes  and  ankle  freely.  He  has  some  pain 
in  the  leg.  During  the  night  the  toes  were  numb  and  insensitive  to  touch. 

May  23d. — The  swelling  of  the  limb  has  decreased.  The  thrill  extends 
higher  over  the  aneurism  and  along  the  course  of  the  external  iliac  artery 
than  before  the  operation.    The  band  is  probably  responsible  for  this. 

I  may  remark  here  that  the  thrill  has  been  an  important  guide  to  us  in 
the  conduction  of  our  experimental  and  clinical  work,  for  it  indicates  quite 
accurately  the  degree  of  constriction  which  has  been  attained.  In  the  his- 
tories of  our  experiments  we  read,  "  Artery  has  been  constricted  to  the 
thrill -point,"  or  "  thrill -points  passed  but  pulse  perceptible,"  or  "  thrill  and 
pulse  obliterated  but  lumen  of  vessel  not  completely  closed." 

May  25th. — Patient  is  free  from  pain.  Sensation  and  temperature  of  the 
limb  are  normal.  A  previously  much-dilated  tributary  of  the  long  saphenous 
vein  is  no  longer  visible.   There  is  a  suspicion  of  pulsation  in  the  aneurism. 

June  6th. — The  swelling  of  the  limb  has  steadily  decreased  since  the 
operation.   There  is  a  very  faint  but  definite  pulsation  in  the  aneurism. 

Second  Operation. — Excision  of  the  aneurism.  June  7th:  The  skin 
having  been  disinfected  with  alcohol  and  tincture  of  iodine,  the  entire  field 
of  operation,  including  scrotum,  penis,  abdomen,  gluteal  region  and  anterior 
surface  and  sides  of  thigh  were  covered  with  a  layer  of  very  thin  linen  soaked 
in  celloidin.  A  long  vertical  incision  was  made  through  the  dried  celloidin 
and  linen  over  the  greatest  convexity  of  the  aneurism.  Before  resorting  to 
temporary  occlusion  of  the  common  iliac  artery  an  attempt  was  made  to 
enucleate  the  sac  to  the  extent  which  might  prove  feasible  (1)  in  the  hope 
that  it  might  be  unnecessary  to  complicate  the  operation  by  the  dissection 
of  the  common  iliac  and  (2)  because  I  wished  to  note  the  condition  of  the 
circulation  in  the  anastomotic  vessels  as  well  as  in  the  femoral  vein  and 
artery.  The  tissues  over  and  about  the  aneurism  seemed  to  be  abnormally 
vascular,  many  more  clamps  than  usual  being  required  to  control  the  bleed- 
ing. Two  large,  flattened  and  apparently  obliterated  veins  lay  over  the 
inner  part  of  the  sac.  The  epigastric  and  external  iliac  vessels  had  been 
dissected  out  and  tied,  and  the  enucleation  of  the  sac,  above  and  at  the  sides, 
bloodlessly  executed,  when  I  decided  that  much  time  would  be  saved  by 
making  temporary  compression  of  the  common  iliac.  This  vessel  was  exposed 


400  ILIO-FEMORAL  ANEURISM 

by  cutting  upward  over  the  left  rectus  muscle  in  the  line  of  the  scar  of  the 
original  incision.  A  broad  tape  was  wound  twice  around  the  common  iliac, 
twisted  until  the  artery  was  occluded,  and  the  twist  maintained  by  a  clamp. 

The  aneurism  was  found  to  terminate  below  in  a  broad  funnel  from  the 
inner  and  posterior  side  of  which  a  large  artery,  presumably  the  profunda, 
was  given  off.  Just  below  the  funnel-shaped  dilatation  of  the  femoral,  this 
artery  was  divided  between  two  ligatures  and  the  sac  dissected  out  from 
below  upward.  A  cord-like  stricture,  later  supposed  to  be  the  femoral  vein, 
was  cut  across  and  dissected  up  with  the  sac.  The  external  iliac  artery, 
without  change  in  its  size,  plunged  abruptly  into  the  sac  at  the  upper  part 
of  its  posterior  surface.  The  aneurism  was  then  split  longitudinally  from 
one  end  to  the  other  and  the  clots  rapidly  evacuated.  The  wall  was  per- 
fectly dry,  not  a  single  bleeding  point  being  seen.  The  sac  was  found  to 
extend  deeply  into  the  pelvis.  It,  undoubtedly,  had  pressed  on  the  internal 
iliac  vessels  and  their  branches.  The  further  liberation  of  the  sac  was  very 
easily  and  swiftly  carried  out,  not  a  single  vessel  being  divided  except  by 
the  final  stroke  of  the  knife  which  severed  the  proximal  end  of  the  external 
iliac  vein.  This  vessel  having  been  occluded  and  cut  through  in  its  periph- 
eral part  was  not  definitely  identified  until  redivided.  Altogether  the 
operation  was  carried  out  in  a  bloodless  manner. 

The  sutured  wound  was  45  cm.  in  length.  It  was  closed  without  drainage 
except  for  one  short  cigarette  of  gutta-percha  tissue.  A  silver-foil  dressing 
was  applied.  After  the  operation  the  left  foot  and  leg  up  to  the  knee  were 
distinctly  cooler  than  the  right.  A  difference  in  the  temperature  of  the  two 
legs  was  observable  until  the  fifth  day. 

On  recovery  from  the  anaesthesia  the  patient  could  move  the  toes  and 
ankle  freely.  He  stated  that  his  foot  felt  numb,  but  he  could  locate  accu- 
rately pin-pricks  at  every  point  except  along  the  inner  margin  of  the  nail 
of  the  great  toe,  and  could  readily  distinguish  heat  from  cold. 

June  11th. — First  dressing.  Wound  healed  throughout  by  first  intention 
except  for  the  drainage  opening.  Patient  has  been  remarkably  comfortable, 
requiring  no  morphine  since  the  operation.  The  swelling  throughout  the 
entire  limb  has  greatly  decreased.  There  has  been  no  distention  of  the 
abdomen,  notwithstanding  the  transperitonaeal  exposure  of  the  common  iliac 
artery. 

July  16th. —  (Nine  days  after  operation.)  Patient  has  been  walking 
about  for  several  days.  He  states  that  his  leg  is  absolutely  comfortable  and 
rapidly  gaining  in  strength.  The  entire  limb  is  soft  and  quite  natural.  The 
circumference  of  the  thigh  measures  11  cm.  less  than  before  operation. 
Elsewhere  the  swelling  has  decreased  proportionately. 

November,  1918. — Patient  writes  enthusiastically  of  his  present  condi- 
tion. He  states  that  he  observes  no  sign  of  swelling  or  loss  of  power  or 
sensation  in  the  left  leg,  and  that  he  is  able  to  do  a  hard  day's  work  without 
unusual  fatigue. 

I  have  cited  this  case  at  such  length  because  it  seems  to  me  to  demonstrate 
quite  convincingly  that  the  employment  of  the  metal  band  was  not  without 
avail.  One  might  well  perhaps  allow  a  longer  time  for  the  establishment  of 
the  collateral  circulation,  but  in  this  instance  it  was  not  possible  to  do  so 
as  I  was  to  sail  for  Europe  two  days  after  the  second  operation. 


PARTIAL,  PEOGEESSIVE  AND  COMPLETE  OCCLUSION"  OF  THE 

AORTA  AND  OTHER  LARGE  ARTERIES  IN  THE  DOG 

BY  MEANS  OF  THE  METAL  BAND ' 

At  the  meeting  of  The  Johns  Hopkins  Hospital  Medical  Society, 
March  20,  1905,  a  brief  preliminary  report  was  made  of  the  results  of 
experiments  in  occlusion  upon  the  abdominal  aorta  and  other  arteries  of 
sixty-three  dogs,  conducted  during  the  previous  winter  and  autumn  by 
Dr.  W.  F.  M.  Sowers  and  me.2  During  the  following  year  these  investigations 
were  continued  with  the  assistance  of  Dr.  E.  H.  Richardson,  thirty-nine 
dogs  being  operated  upon.  "With  the  aid  of  a  modified  Brauer  apparatus 
devised  by  Dr.  Follis  and  Dr.  Fisher  we  were  able  successfully  to  constrict 
the  thoracic  aorta  both  in  animals  and  man.  In  June,  1906,  at  the  meeting 
of  the  American  Medical  Association  in  Boston,  attention  was  again  called 
to  our  work,  the  results  to  date  being  given  in  merest  outline.3  During  the 
following  two  years,  the  exigencies  of  the  surgical  clinic  seemed  to  demand 
experimental  investigation  in  another  direction  and  hence  only  a  little  time 
was  found  for  prosecuting  the  arterial  work  under  consideration,  although 
several  problems  which  have  arisen  in  connection  with  it  we  regard  with 
unabated  interest;  and  with  the  solution  of  these  we  are  again  concerning 
ourselves.  In  the  meantime,  however,  a  number  of  experiments  have  been 
made,  and  several  animals  which  were  for  many  months  under  observation 
have  furnished  additional  facts  worthy  of  record.  The  method  of  applying 
the  band  has  been  improved  and  modified  and  new  instruments  for  rolling 
it  devised.  The  full  report  of  this  work  will  probably  be  published  during 
the  year  in  The  Johns  Hopkins  Hospital  Reports. 

The  incentive  to  the  work  was  the  desire,  experienced  by  so  many  sur- 
geons of  the  past  and  present,  to  be  able  to  occlude  safely  the  abdominal 
aorta  in  the  hope  of  curing  thereby  aneurisms  of  this  vessel  and  of  the 
common  iliac  arteries.  I  shall  write  later  of  the  attempts  of  Dubois,  Assalini, 
Bujalsky,  Pirogoff,  Luigi  Porta,  Cooper  and  Keen  to  compress  gradually 
the  abdominal  aorta  by  means  of  specially  devised  instruments  which,  passed 
through  an  incision  in  the  abdominal  wall,  carried  a  snare  of  silk,  catgut  or 

1  Received  for  publication  January  14,  1909. 
J.  Exper.  M,  Lancaster,  Pa.,  1909,  xi,  373-391. 

2  Johns  Hopkins  Hospital  Bulletin,  1905,  xvi,  346. 

3  Jour,  of  the  Amer.  Med.  Assoc,  1906,  xlvii,  2147. 

27  401 


402  OCCLUSION  OF  AKTERIES 

metal  which  might  at  any  moment  be  tightened  or  loosened  at  will.  A  fault 
common  to  all  of  the  methods  hitherto  devised  is  seemingly  an  insurmount- 
able one — the  difficulty  of  preventing  sepsis  in  the  track  of  an  instrument 
maintaining  direct  communication  for  days  or  even  weeks  with  the  air. 
A  better  method  might,  we  thought,  be  one  permitting,  in  each  entre-act, 
complete  closure  of  the  wound.  The  material  compressing  the  aorta  should 
not  be  bulky  nor  endanger  by  its  form  or  substance  the  adjacent  parts ;  and 
it  should  admit  of  easy  readjustment  at  subsequent  operations,  should  they 
be  indicated.  Metal  bands  of  silver  and  then  of  aluminium  were  employed 
with  the  hope  that  the  amount  of  constriction  might  be  regulated  to  a  nicety 
at  prospective  subsequent  operations  as  well  as  at  the  primary  one.  With 
the  aid  of  an  ingenious  clock-maker,  an  instrument  was  devised  to  curl  a 
metal  strip,  in  perfect  cylinder-form,  about  the  vessel. 

The  tightening  of  the  band  is  completed  with  the  fingers;  but  in  the 
early  experiments,  when  the  metal  employed  was  too  thick  and  the  bands 
too  broad,  the  aid  of  tweezers  was  required.  We  observed  the  first  group  of 
dogs  with  some  apprehension,  fearing  that  the  edges  of  the  band  would  cut 
the  much  constricted  and  powerfully  pulsating  aorta,  and  were  considering 
ways  to  obviate,  if  necessary,  this  danger.  On  the  twelfth  day  after  operation 
a  dog  died  of  haemorrhage,  the  result  of  ulceration  at  the  upper  edge  of 
the  band.    The  experiments  were  thereupon  discontinued  for  a  while,  to 
await  results  in  the  other  dogs  carrying  aortic  bands.    Further  cases  of 
haemorrhage  not  occurring,  we  resumed,  in  a  few  weeks,  the  experiments. 
About  three  months  later  we  investigated,  at  second  operations  and  at 
autopsy,  the  resultant  conditions  and  found  that  the  aortic  wall  where  the 
band  had  embraced  it  was,  in  each  instance  of  complete  occlusion,  atrophied, 
being  reduced  in  some  cases  to  a  film-like  thinness.   Notwithstanding  these 
somewhat  discouraging  observations  the  experiments  were  continued  as 
actively  as  time  permitted  in  the  hope  that,  with  an  improved  technique, 
derived  from  greater  experience,  particularly  with  reference  to  precision 
in  the  determination  of  the  degree  of  closure  brought  about  as  the  rolling 
(tightening)  of  the  band  proceeded,  the  walls  of  the  arteries  might  retain 
their  vitality  even  in  the  case  of  complete  arterial  occlusion  (vide  Cases  27 
and  28).   By  reducing  the  width  and  length  of  the  band  and  the  thickness 
of  the  metal,  Ave  were  able  with  the  fingers,  and  with  ease,  to  occlude  the 
artery  to  the  extent  desired.  From  the  first  experiment  we  have  endeavored, 
in  each  instance,  to  roll  the  band  as  perfectly  (as  cylindrically)  as  possible, 
flattening  of  it  being  assiduously  guarded  against.  To  control  with  accuracy 
the  amount  of  blood-flow  under  the  band,  the  rolling  must  go  on  smoothly 
and  under  the  perfect  command  of  the  operator.    The  thrills  of  various 
strength,  the  point  at  which  the  pulse  disappears,  are  carefully  noted  in 


BY  METAL  BANDS  403 

the  course  of  the  act  of  constricting  the  vessel ;  and,  finally,  when  complete 
occlusion  is  desired,  the  pulse  being  no  longer  distinguishable,  the  filling 
or  not  of  the  artery  below  the  band,  between  it  and  a  fine  clamp  placed  cen- 
tral to  the  first  distal  branch  is  our  only  clue  as  to  the  patency  of  the  artery. 

With  the  use  of  silk  or  even  silver  wire  such  delicate  manipulation  and 
determination  were  found  impossible,  irrespective  of  the  great  danger  of 
injury  to  the  vessel  wall  from  attempts  to  draw  just  a  shade  tighter  a  half- 
knotted  thread  which  has  constricted  the  vessel  almost  to  the  occlusion  point. 

At  the  time  of  my  first  report  (March,  1905 )4  we  stated  that:  (1)  If 
applied  tightly  enough  to  interrupt  completely  the  circulation,  the  band 
had  usually  caused  atrophy  and  frequently  complete  absorption  of  the  aortic 
wall.  In  such  cases  haemorrhage  was  invariably  prevented  by  the  formation 
of  connective  tissue  enclosing  the  band.  (2)  Thrombosis  had  not  been 
observed  in  a  single  instance,  either  in  the  cases  of  complete  occlusion  in 
which  the  arterial  wall  under  the  band  was  found  so  greatly  thinned,  or  in 
those  in  which  it  had  been  absorbed.  (3)  In  a  few  cases  (vide  No.  28)  aortic 
walls  drawn  together  so  snugly  that  at  autopsy  water  could  not  be  forced 
through  with  a  syringe  were,  on  division  of  the  band,  found  to  be  normal 
and  could  be  easily  smoothed  out  and  the  full  lumen  reestablished.  But  in 
these  earlier  cases  of  complete  occlusion  the  aortic  wall  had  almost  invari- 
ably atrophied,  having  been  so  tightly  constricted  as  to  be  deprived  of  its 
blood  supply,  and  hence  the  "ideal  obliteration"  (reported  the  following 
year)  by  adhesion  of  the  folded  intima  and  the  conversion  of  the  constricted 
portion  of  the  artery  into  a  solid  fibrous  cylinder  (vide  Plate  XXIX,  2a), 
could  not  have  taken  place.  (4)  The  less  snugly,  the  loosely  and  the  very 
loosely  applied  bands  might  remain  on  the  aorta,  femorals  and  carotids  for 
months  without  apparent  injury  to  the  walls  of  these  vessels,  either  exter- 
nally or  internally.  For  example,  the  band  after  one  hundred  days  would  be 
seen  shimmering  brightly  under  a  quite  normal-looking  peritonaeum,  hav- 
ing caused,  as  a  rule,  little  if  any  reaction,  and  could  be  as  easily  removed 
from  the  wall  of  the  artery  as  when  originally  applied.  (5)  We  were  encour- 
aged to  believe  that  there  might  be  a  place  in  surgery  for  the  partially 
occluding  band,  and  reported  its  application  to  the  common  carotid  artery 
in  the  human  subject  and  the  manifestation,  thereupon,  of  slight  brain 
symptoms  which  persisted  for  several  months.  In  this  case  the  band  was 
rolled  more  tightly  than  intended.  It  might  easily  have  been  removed  and 
reapplied  but,  as  I  stated  at  the  time,  our  notions  being  somewhat  vague 
as  to  the  precise  amount  of  constriction  to  be  desired  and  being  unable  to 
determine  accurately  the  blood  pressure  distal  to  the  band  we  decided  not 
to  disturb  it  and  to  note  results.    On  the  appearance  of  the  head  symptoms 

4  Loc.  tit. 


404  OCCLUSION  OF  ARTERIES 

I  did  not  relieve  the  constriction,  believing  that  they  would  probably  dis- 
appear ;  furthermore,  I  was  not  perfectly  sure  that,  rather  than  good,  harm 
might  not  result  from  the  release  of  the  carotid. 

Subsequently  (in  June,  1906),  in  the  report  made  in  Boston  before  the 
Section  on  Surgery  and  Anatomy  of  the  American  Medical  Association,  the 
following  newly  observed  facts  were  emphasized : 

1.  The  blood  pressure  in  the  aorta  below  the  band  is  lowered  in  proportion 
to  the  amount  of  the  occlusion.  The  rise  in  pressure  below  the  band  is, 
at  first,  rapid,  but  varies  considerably  in  the  different  dogs.  For  example, 
in  one  dog,  a  rise  below  the  band  of  ten  millimetres  (Hg.  manometre)  was 
noted  in  ten  minutes,  whereas,  in  another  dog,  two  hours  were  required  for 
a  rise  of  fifteen  millimetres.  For  the  return  of  the  normal  pulse  wave  and 
of  the  normal  blood  pressure  as  many  as  seven  months  have  been  insufficient 
(vide  history  of  Dog  No.  96 ).3 

2.  Partially  occluding  bands  produced,  as  a  rule,  no  macroscopic  altera- 
tion in  the  aortic  wall  under  the  band  even  after  seven  and  eight  months 
(vide  Plate  XXIX,  1).  Under  completely  occluding  bands  the  arterial 
wall  had  (to  the  date  of  the  second  communication  referred  to)  usually 
atrophied  and  in  the  course  of  weeks  or  months  been  absorbed.  "  When  the 
lumen  had  been,  perhaps,  not  quite "  occluded,  complete  obliteration  might 
result  spontaneously  with  the  conversion  of  the  arterial  ivall  embraced  by 
the  band  into  a  solid  cylinder  of  living  tissue.  This  may,"  I  stated,  "be 
considered  the  ideal  closure  of  an  artery."  Although  this  form  of  arterial 
closure  had  occurred  only  thrice  in  the  long  series  of  experiments,  it  might, 
I  thought,  be  accomplished  frequently,  and  ultimately  the  band  might  be 
applied  with  such  nicety  that,  unaided,  further,  by  the  surgeon,  a  partial 
would  be  likely  to  proceed  to  total  occlusion. 

3.  "  The  Effects  on  the  Spinal  Cord  and  Its  Coverings. — The  study  of 
the  spinal  cords  was  entrusted  to  Mr.  P.  K.  Gilman  (later  Dr.  Gilman  and 
member  of  my  staff),  who  discovered,  in  a  number  of  instances/  about  three 

"Since  this  statement  was  made  we  have  had  several  opportunities  to  verify 
it,  and  have  noted  in  a  dog  with  partially  occluding  band  on  the  thoracic  aorta, 
after  seven  months,  a  difference  of  30  millimetres  or  more  in  the  pressure  im- 
mediately above  and  immediately  below  the  band.  Of  particular  interest  are 
the  careful  observations  of  Dr.  Percy  M.  Dawson  on  the  femoral  and  carotid 
pressures  in  Dog  No.  96  of  this  series,  reported  below. 

*  We  have  not  as  yet  learned  to  determine  with  the  greatest  precision  the 
degree  of  arterial  occlusion  effected,  nor  am  I  convinced  that  in  all  of  the  cases 
in  which  the  "  ideal  occlusion "  has  resulted  (we  have  now  five  such  observa- 
tions) there  may  not  have  been,  at  the  outset,  complete  obliteration  of  the  lumen 
(vide  history  of  Dog  No.  27). 

T  These  proved  to  be  cases  in  which  total  or  almost  total  occlusion  had  been  made. 


BY  METAL  BANDS  405 

months  after  operation,  a  deposit  of  extradural  fat  about  the  cord  below  the 
site  of  the  aortic  band.  In  three  cases  the  production  of  fat  was  so  great  that 
it  filled,  seemingly  under  considerable  tension,  the  vertebral  canal/' 

If  these  observations  should  prove  to  be  correct,  Mr.  Gilman  has  made  a 
discovery  of  wide  significance. 

4.  That  in  the  human  subject  I  had  partially  occluded  the  innominate 
artery  once  and  the  common  carotid  four  times.8  In  the  case  of  a  large  pop- 
liteal aneurism  I  had  employed  the  metal  band  to  occlude  completely  the 
femoral  artery.  In  the  case  of  a  woman  asphyxiated  to  unconsciousness  by 
an  aneurism  of  the  aortic  arch,  I  had  exposed,  carefully  and  freely  and  with- 
out puncturing  either  pleural  cavity,  the  heart  and  arch  of  the  aorta,  hoping 
to  be  able  to  encircle  with  a  band  the  aortic  arch  between  the  regions  of  the 
innominate  and  left  carotid  arteries,  but  the  aneurism  was  so  extensive  and 
the  patient's  condition  so  desperate  as  to  defeat  the  earnest  and  prolonged 
endeavor  to  execute  the  procedure. 

The  Aluminium  Band  and  the  Manner  of  Its  Application  to 
the  Aetert 

We  have  tested  only  two  of  the  metals,  silver  and  aluminium,  with  refer- 
ence to  their  adaptability  to  the  procedure  under  consideration.  After  a 
few  experiments  with  the  former  it  was  discarded.  The  greater  weight  and 
value  of  the  silver  (there  is  great  waste  in  its  use)  and  the  inconstant  results 
obtained  as  to  nicety  in  rolling,  particularly  after  repeated  boilings,  are  the 
principal  factors  which  led  to  its  disuse.  The  aluminium,  usually  purchased 
in  sheets  of  about  25  degrees  of  thickness  (American  scale)  should  be  cut, 
before  being  rolled  down  to  the  thinness  desired,  into  strips  of  convenient 
length,  and  of  width  not  greater  than  three  quarters  of  an  inch.  If  much 
wider,  the  strips  warp  inconveniently  and  have  to  be  cut  to  waste  in  the 
selection  of  flat  and  regular  parts  for  band  material.  It  is  well  to  stamp 
each  strip  with  the  numbers  indicating  the  thickness  of  the  metal  and  to 
have  on  hand  a  liberal  supply  of  the  various  thicknesses  from  No.  25  to 
No.  46.  The  finest  numbers  we  have  used  on  the  very  small  femoral  and 
renal  arteries  of  the  dog.  In  the  average  dog  for  the  abdominal  aorta  Nos.  34 
to  35  are  suitable,  and  for  the  thoracic  aorta  Nos.  33  and  34  we  have  used 
most  frequently.  In  the  human  subject  for  the  abdominal  aorta  below  an 
aneurism  near  its  bifurcation  No.  33  sufficed,  but  ordinarily  a  heavier  size 
would  be  required ;  for  the  common  iliac  No.  32  answered  the  purpose 

8  The  aluminium  band  has  now  been  successfully  applied  in  man  to  the  common 
carotid  artery  twelve  times,  and  once  each  to  the  thoracic  aorta,  the  abdominal  aorta, 
the  common  iliac,  the  femoral,  and  the  innominate  arteries.  These  cases  will  be  re- 
ported later  in  the  Amer.  Jour,  of  the  Med.  Sciences. 


406  OCCLUSION  OF  AETEEIES 

admirably;  for  the  thoracic  aorta  Xos.  22  to  25  perhaps;  for  the  common 
carotid  we  have  almost  invariably  selected  Xo.  33.  The  length  of  the  band 
should  be  about  that  of  the  circumference  of  the  full  artery.  The  width 
varies  from  about  2  mm.  for  the  renal  arteries  in  the  dog  to  about  1  cm.  for 
the  thoracic  aorta  and  innominate  artery  in  man.  Plate  XXVIII.  1,  b, 
depicts  a  band  suitable  in  width  for  the  human  carotid  and  for  the  average 
dog's  abdominal  aorta.  The  band  in  this  illustration  we  should  now  regard 
as  too  long  for  its  breadth  by  approximately  one  third.  It  is  best  to  sterilize 
the  aluminium  only  once.  It  may  become  too  brittle  for  perfect  rolling  by 
repeated  boilings.  When  rolled  down  on  the  artery  enough  almost  to  oblit- 
erate the  pulse,  a  band  of  seemingly  proper  dimensions  has  rarely  described 
more  than  two  complete  circles.  The  filing  or  "  manicuring  "  of  the  band 
is  of  very  great  importance.  It  should  be  curved  like  a  finger  nail  at  the 
forward  end  and  at  the  other  cut  precisely  at  right  angles  to  its  long  axis. 
With  a  file  the  edges  should  be  made  perfectly  smooth,  but  not  sharp,  and 
the  rounded  end  symmetrical.  A  carefully  filed  band  coils  more  easily  both 
in  the  instrument  and  under  the  fingers,  and,  what  is  more  important,  is  not 
likely  to  cut  the  artery.  The  aorta  is  the  only  vessel  that  I  have  seen  cut 
itself  on  the  band,  and  then,  with  the  exception,  perhaps,  of  two  very  young 
dogs  or  puppies,  only  when  the  band  was  badly  filed  or  clumsily  rolled,  as  in 
the  early  experiments,  especially  those  in  which  forceps  were  employed  to 
supplement  the  work  of  the  fingers  in  tightening  the  too  broad  and  too 
heavy  bands  at  that  time  employed.  Silk  ligatures,  even  when  occluding  the 
aorta  only  partially,  have  in  my  experiments  repeatedly  cut  entirely  through 
the  aorta,  and  without  causing  the  death  of  the  animal.  They  may  leave  in 
their  wake  various  forms  of  diaphragm  which  more  or  less  obstruct  the 
lumen  of  this  artery.  I  shall  refer  to  a  case  of  this  kind  depicted  in 
Plate  XXIX,  3  and  4. 

The  Band  Curler.— The  original  instrument  {vide  Plate  XXVIII)  had, 
we  soon  discovered,  three  major  faults.  It  was  ( 1 )  too  broad  at  the  arterial 
end,  (2)  the  band  lacked  anterior  support  as  it  was  being  pressed  onward 
by  the  driving  blade,  a  (magnified  a'),  and  (3)  the  latter  did  not  always 
engage  the  former,  owing  to  the  fact  that  it  was  too  springy  and  was  insuffi- 
ciently linked  to  its  fellow  on  which  it  glides.  To  remedy  the  tendency  for 
the  band  to  buckle  forward,  one  was  compelled  to  support  it  with  the  finger 
during  the  process  of  curling.  This  was  occasionally  a  difficult  and  usually 
an  awkward  performance. 

Plate  XXVIII,  2  shows  an  improved  and  satisfactory  band  roller  or 
curler.  In  the  full  length  drawing  the  instrument  is  not  loaded;  in  the 
abbreviated  sketch  the  band  projects  from  the  end,  half  curled.  The  prin- 
cipal defects  of  the  old  instrument  have  been  remedied  in  the  new.  Buckling 


BY  METAL  BANDS  407 

of  the  band  is  prevented  by  the  boxing;  the  driving-plate  cannot  spring 
away  from  its  fellow,  and  the  width  of  the  instrument  has  been  sufficiently 
reduced  to  permit  it  to  be  passed  freely  between  the  closely  given  off 
branches  of  the  abdominal  and  thoracic  aortas.    When  the  thinner  bands 
are  used  it  is  sometimes  necessary  to  give  the  faintest  tip  backwards  to  each 
of  the  two  right-angled  corners  of  the  band  to  insure  its  engagement  in 
the  downward  thrust  of  the  piston  or  driving  blade.   After  it  has  encircled 
the  artery  the  band  may,  if  its  corners  have  been  bent,  be  freshly  squared 
with  the  scissors  before  being  curled  tighter  by  the  fingers.    This  is  not, 
however,  necessary.    The  curler  being  armed  with  the  carefully  filed  band 
of  correct  proportions,  the  plunger  is  made  to  engage  the  band  and  to  force 
its  convex  end  into  sight  before  the  instrument  is  passed  under  the  artery. 
In  Plate  XXVIII,  1,  the  act  of  curling  the  band  about  the  artery  is  shown, 
after  the  old  manner,  in  its  first  stage.   As  the  curling  proceeds  the  instru- 
ment is  gradually  withdrawn.   In  arranging  for  the  tightening  of  the  band, 
its  convex  end  should  lie  on  the  wall  of  the  artery  and  be  overlapped  by  the 
square  end.    With  a  very  little  practice  one  learns  to  avoid  bending  or 
flattening  the  band  in  the  process  of  tightening  it.  The  band  should  be  long 
enough  to  encircle  the  artery  in  the  expanded  state  of  the  latter  and  the 
metal  should  be  sufficiently  thick  and  wide  to  sustain  the  curl  given  it.   If 
perfectly  rolled  the  inside  and  outside  circles  of  the  metal  touch  each  other 
at  all  points  of  the  surface  of  contact  and,  in  consequence,  the  cohesion  force 
is  greatest.   The  artery  should  be  raised  from  its  bed  by  two  tapes  held  far 
enough  apart  to  leave  uncovered  sufficient  free  space  on  the  artery  for  the 
occupancy  of  the  band.    Traction  on  the  upper  tape  should  be  made  to 
interrupt  the  blood  current  and  thus  to  reduce  the  size  of  the  vessel.  A  band 
curler  should  be  selected  (we  have,  at  present,  four  sizes  of  this  instrument) 
which  might  make  the  metal  describe  a  circle  smaller  than  the  distended 
or  full  artery  but  a  little  larger  than  the  empty  one ;  then,  with  the  return 
of  the  blood  current,  the  artery  expands  and  may  fill  the  band  quite  snugly. 
After  complete  occlusion  of  the  abdominal  aorta  the  femoral  pulse  does 
not,  usually,  return  for  weeks  or  even  months.   And  after  incomplete  occlu- 
sion of  the  thoracic  aorta  (Dog  No.  96)  the  femoral  pulse  may  be  hardly 
discernible  after  seven  months.    The  anastomotic  circulation  takes  place 
through  the  vasa  vasorum  as  discovered  and  so  beautifully  depicted  by 
Luigi  Porta,9  and  by  way  of  the  internal  mammary  and  epigastric  arteries 
as  especially  emphasized  by  Kast.10   We  have  repeatedly  observed  the  great 
increase  in  the  vascularity  of  the  abdominal  wall,  particularly  on  splitting 

9  Luigi  Porta,  Delle  alterazioni  patologiche  delle  arterie  per  la  legatura  e  la  torsione, 
Milan,  1845. 

10  Kast,  Deut.  Zeit.  fur  Chirurgie,  1879,  xii,  405. 


408  OCCLUSION  OF  ARTERIES 

the  recti  muscles  but  also  in  making  mid-line  incisions  at  operations  subse- 
quent to  the  one  at  which  the  band  was  applied. 

Dog  No.  2. — Large,  savage,  collie-like  dog.  Operation  I.  Morphia  and 
ether.11  November  4,  1904.  Silver  band,  partially  occluding  the  vessel, 
applied  to  the  abdominal  aorta  below  (?)  the  inferior  mesenteric  artery. 
Radicles  of  thoracic  duct  not  injured.  Pulse  in  femorals  easily  countable 
at  end  of  operation,  though  much  reduced  in  volume. 

November  6, 190 Jf. — Dog  in  good  condition,  rather  dull,  walks  about  with- 
out apparent  weakness  in  hind  legs.  Tests  such  as  running  up  stairs  were 
not  made. 

November  10,  190\. — Apparently  perfectly  well.  Is  quite  savage  and 
threatens  to  bite  when  cage  is  entered. 

December  8,  190k. — Vigorous  femoral  pulse  but  seemingly  weaker  than 
might  be  expected  in  so  large  a  dog.  Health  has  been  perfect.  Operation  II. 
Morphia  and.  ether.  Complete  occlusion  of  aorta  about  1  cm.  above  the  silver 
band  by  heavy  black  silk  ligature.  The  silver  band  glistened  through  a  very 
thin  and  apparently  normal  peritonaeum.  It  had  excited  little  or  no  irrita- 
tion. On  coming  out  of  ether  the  dog  showed  signs  of  unusual  excitement. 
Respirations,  136  per  minute.  One  hour  after  operation  dog  was  able  to 
climb  a  flight  of  stairs.  The  hind  legs  were,  however,  in  spastic  condition, 
flexed  on  the  abdomen,  at  the  knees  and  hips,  and  very  much  weaker  than 
the  fore  legs. 

December  10,  1901+. — Dog  is  dull.  Hind  legs  are  dragged  in  walking  but 
are  not  completely  paralyzed.   Movements  still  spastic. 

December  llf,  190)+. — Is  lively  and  seems  quite  well.  Bladder  and  rectum 
function  normally.  Scratches  himself  with  left  hind  leg  without  apparent 
weakness. 

January  21,  1905. — Femoral  pulses  not  yet  definitely  palpable  but  the 
arteries  have  become  quite  full. 

February  1,  1905. — Femoral  pulse  faint  and  not  countable. 

February  20,  1905. — Fair  pulse,  countable. 

March  6,  1905. — Found  dead.  Was  not  observed  yesterday  (Sunday). 
Autopsy. — A  large  flat  cork  causing  intestinal  obstruction  is  the  cause  of 
death.  The  silk  ligature  above  the  band  has  cut  almost  through  the  aorta, 
its  track  being  apparently  healed;  part  of  the  loop  projects  into  a  little 
cavity,  with  newly  formed  walls  of  connective  tissue,  adjacent  to  and  in 
front  of  the  wall  of  the  aorta.  A  filmy  substance,  like  decolorized  blood 
clot,  is  adherent  to  the  track  taken  by  the  ligature  in  its  course  through 
the  artery.  The  aorta  under  the  band  is  a  little  thinned.  Its  endothelial 
lining  seems  normal. 

In  the  light  of  subsequent  experience  it  seems  probable  that  the  thinning 
of  the  aorta  may  have  been  caused  by  the  ligature  applied  so  close  above  the 
band — by  its  interference  with  the  circulation  in  the  arterial  wall. 

Dog  No.  6. — Black  bitch,  length  31  inches.  November  19,  1904.  Opera- 
tion I.  Closure  of  abdominal  aorta  with  aluminium  band  1  cm.  in  width. 

"All  the  animals  were  anaesthetized  in  the  same  way  preparatory  to  operation. 


BY  METAL  BANDS  409 

The  pulse  pressure  in  the  left  femoral  artery  as  recorded  by  an  assistant : 

Before   operation    150  mm. 

After  abdomen  was  opened   130  mm. 

Band   incompletely   tightened    80  mm. 

Tightening   of  band   completed    20  mm. 

After  abdominal  manipulations  were  ended  25  mm. 

After    closure    of   abdomen    30  mm. 

The  operators  could  not  feel  the  aortic  pulse  below  the  band  after  it  was 
completely  curled,  hence  I  have  doubt  as  to  the  accuracy  of  the  three  obser- 
vations on  pulse  pressure  in  the  femoral  artery  made  after  the  final  tighten- 
ing of  the  band. 

November  21,  190)+. — Femoral  pulse  doubtful.  Dog  ran  easily  on  level 
and  mounted  the  first  steps  of  a  flight  of  stairs  without  definite  signs  of 
weakness.  Her  hind  legs  gave  out  before  the  top  steps  were  reached. 
Temperature  forefeet,  70°,  hind  feet,  66°,  Fahrenheit. 

November  22,  190k- — Hind  legs  still  weak.  Sits  down  after  slight  exer- 
cise. Pulse  in  femorals  doubtful.  Surface  temperature  of  hind-flanks,  95° ; 
fore-flanks,  97°;  pads  of  feet,  hind  97°;  front,  71°. 

November  25, 1901+. — Temperature  axilla,  98.5°  ;  groin,  95.5°.  Hind  legs 
less  weak.  Dog  in  good  spirits.  Operation  II,  11 :  30  a.  m.  Ligature  of  black 
silk  obliterating  aorta  applied  below  the  band.  3  p.  m.,  bladder  not  dis- 
tended. Bitch  has  showed  no  excitement  since  operation.  Temperature, 
axilla,  96°;  groin,  93°  F. 

December  13,  190J+. — Slightly  stiff  in  hind  legs.  Dog  is  dull  and  indis- 
posed to  walk  much.  We  attributed  the  condition  of  the  dog  in  part  to 
one-half  grain  of  morphia  administered  before  operation. 

December  11/.,  1904. — Movements  in  hind  legs  greatly  improved.  Dog 
walks  with  ease  but  is  a  little  depressed  and  sits  down  frequently. 

December  19,  190b. — Perfectly  well  and  active. 

December  28,  1901/.. — Well  and  active. 

January  7, 1905.— Well. 

January  12,  1905. — Well. 

January  19,  1905. — Well  and  strong.  Faint  femoral  pulse  observed  for 
the  first  time  since  the  first  operation  performed  two  months  ago. 

January  23, 1905. — Femoral  pulse  definite. 

February  1,  1905. — Femoral  pulse  countable  but  is  still  very  small. 

March  6,  1905. — Dog  well  but  quite  thin.  Killed  with  ether.  Femoral 
and  thoracic  conditions  normal.  On  palpating  aorta  a  small  nodule  is  felt  at 
site  of  ligature.  The  band  is  found  directly  in  line  of  the  aorta  above  the 
ligature  and  filling  completely  a  new-formed  connective  tissue  cavity.  The 
arterial  wall  under  the  band  has  been  completely  absorbed  and  the  aortic 
wall  above  the  band  is  continuous  with  the  new  connective  tissue  which 
forms  a  strong  capsule  about  the  band.  The  capsule  of  fibrous  tissue  fits 
the  band  so  closely  that  no  blood  has  escaped  from  the  patulous  aorta  above 
into  the  space  between  the  band  and  the  connective  tissue  which  enclosed  it. 
The  arterial  lumen  just  below  the  band  has  been  obliterated  by  the  silk 
ligature  which  has  cut  entirely  through  the  arterial  wall  and  is  enclosed 
in  a  hard  nodule  of  connective  tissue. 


410  OCCLUSION  OF  ARTERIES 

Dog  No.  20. — Small  puppy,  male.  December  10,  1904.  11  a.  m.  Opera- 
tion. Aluminium  band  applied  above  the  inferior  mesenteric  artery.  In 
exposing  the  artery  the  sigmoid  flexure  was  pulled  to  the  right.  The  band 
had  been  cut  too  long.  It  rolled  beautifully  to  a  certain  point  and  then, 
before  the  aortic  pulse  could  be  obliterated  the  metal  cylinder  began  to 
flatten.  The  pulse  then  became  entirely  obliterated  but  some  sort  of  pulse- 
shock  could  be  felt  for  a  distance  of  1  cm.  or  more  below  the  band. 
1 :  30  p.  m.,  dog  runs  about,  but  his  hind  legs  are  very  weak,  though  not 
completely  paralyzed. 

December  19, 190k- — Hind  legs  stronger. 

December  20,  190 % — Dog  does  not  seem  well.  Is  quite  thin  and  dis- 
inclined to  walk.  Can,  however,  stand  and  uses  his  hind  legs  in  walking 
fairly  well. 

December  28,  1904. — Not  so  well. 

December  26,  190k.— Quite  ill. 

December  27, 190k.— Dead. 

Autopsy. — The  abdominal  wound  had  opened  down  to  the  peritonaeum  but 
was  well  sealed  by  omentum  and  the  subperitoneal  flap  of  fat.  There  is  no 
peritonitis.  The  portion  of  the  ileum  lying  in  the  pelvis,  and  the  sigmoid 
flexure  exhibit  punctate  haemorrhages  in  the  fat  along  the  vessels.  The  sig- 
moid flexure  is  particularly  haemorrhagic  and  probably  the  cause  of  the 
bloody  fluid  in  the  pelvis.  There  is  some  blood  escaping  from  the  anus. 
The  jejunum,  at  a  point  near  the  aorta  where  it  may  well  have  been  pressed 
upon  by  the  retractors  and  gauze,  is  also  indurated  and  dark.  The  bladder 
is  empty.  The  band  has  excited  very  little  reaction.  The  peritonaeum  and 
fat  over  it  are  still  ununited. 

Dog  No.  27. — Small,  black  puppy.  December  26,  1904.  Operation.  A 
very  broad  band  (7  mm.  in  width)  was  placed  on  the  aorta  about  1  cm. 
below  the  inferior  mesenteric  artery  and  rolled  by  tweezers  until  the  demon- 
stration of  a  pulse  below  the  band  was  questionable.  We  attempted  in  this 
case,  prior  to  the  application  of  the  band,  to  produce  occlusion  by  silver  wire 
wrapped  several  times  about  the  artery  and  over  a  small  copper  rod  (the 
rod  to  be  afterwards  withdrawn),  thinking  that  the  size  of  the  lumen  might 
in  such  cases  be  definitely  regulated  by  the  use  of  rods  of  various  sizes. 
After  several  trials  we  were  convinced  that  the  liability  of  injury  to  the 
artery  was  too  great,  at  least  much  greater  than  with  the  employment  of  the 
band.  The  wrapping  of  the  wire  was  also  troublesome.  Hence  the  project 
was  abandoned. 

December  28,  190k. — Walks  fairly  well  but  has  definite  weakness  in  hind 
legs.   Has  fluid  stools  which  contain  a  few  drops  of  blood. 

January  5,  1905. — Weak  and  emaciated.  A  very  small,  not  countable, 
femoral  pulse  has  developed.   Dog  uses  hind  legs  a  little  better. 

January  28,  1905. — Is  very  feeble  and  thin.  Isolated  in  cage. 

January  27,  1905. — It  is  possible  today  for  the  first  time  to  count  the 
femoral  pulse;  it  is  still  very  small. 

February  18,  1905. — Condition  practically  unchanged. 

February  20,  1905. — Seems  a  little  better.  Femoral  pulse  still  very  small, 
but  countable. 

February  28, 1905. — Improvement  continues.  Femoral  artery  feels  fuller. 


BY  METAL  BANDS  411 

April  10,  1905. — Dog  is  very  thin  and  has  the  mange.  Etherized.  A  very 
faint  femoral  pulse  was  demonstrable  on  dissection  of  the  artery,  but  through 
the  skin  it  was  not  definitely  palpable.   Dog  killed. 

Autopsy. — Peritonaeal  cavity  normal. 

The  aortic  band  shimmers  quite  clearly  through  the  peritonaeum,  but 
about  1  cm.  below  the  band  is  a  very  delicate  cicatrix.  The  aorta  was 
split  to  the  band  from  both  ends  and  the  band  itself  divided.  The  vessel  is 
entirely  obliterated  and  the  length  of  the  obliterated  portion  corresponds 
exactly  to  the  width  of  the  band.  The  portion  of  the  aorta  enclosed  by  the 
band  has  become  converted  into  a  solid  fibrous  cord  (vide  Plate  XXIX,  2,  a). 
Outside  the  band  is  a  peculiar,  soft,  yellowish-white  material,  about  one 
drop  in  quantity,  resembling  aleuronat.  The  hard,  white,  living  cord,  into 
which  the  occluded  portion  of  the  aorta  has  been  converted,  is  2  mm.  in 
diameter.  The  band,  an  unusually  broad  and  thick  one,  had  been  in  place 
three  and  one-half  months  and  might,  without  doing  harm,  have  remained 
indefinitely.  The  form  of  the  fibrous  cord,  so  exactly  C}Tlindrical,  under  the 
band,  is  evidence  that  perfection  in  curling  may  be  accomplished  even  with 
tweezers.  Without  especial  effort  to  bring  it  about  we  have  in  five  instances 
obtained  this  ideal  form  of  obliteration — four  times  in  the  aorta  and  once 
in  the  renal  artery — and  always  in  cases  in  which  the  completeness  of  the 
closure  was  in  doubt  at  the  time  of  operation.  This  case  should  be  contrasted 
with  Case  No.  28,  that  of  a  small  puppy  whose  aorta,  though  of  intention 
completely  closed  by  the  band,  was  not  found  converted  into  a  fibrous  cord 
under  the  metal.  To  our  surprise,  it  presented  no  internal  adhesions  what- 
ever on  being  laid  open,  although  so  tightly  constricted  that  not  a  drop  of 
water  could  be  forced  through  this  portion  of  the  vessel  while  the  band  was 
in  place.  The  foldings  of  the  aortic  wall  under  the  band  could  be  smoothed 
out  so  completely  that  no  trace  of  them  remained,  nor  was  there  any  abnor- 
mality of  the  wall  to  indicate  that  a  band  had  been  applied.  We  must  bear 
in  mind  that  in  Dog  No.  28  only  twenty-two  days  had  elapsed  from  opera- 
tion to  autopsy,  whereas  in  the  cases  cited  of  fibrous  cylinder  formation,  the 
dogs  had  carried  their  bands  for  several  months. 

Dog  No.  28. — Small,  black  puppy,  male.  December  26,  1904.  Operation. 
Aluminium  band  rolled  (with  tweezers)  until  pulse  seemed  to  be  obliterated. 

December  28,  190k- — Dog  seems  fairly  well,  but  marked  weakness  and 
stiffness  in  hind  legs. 

January  7,  1905. — Dog  cross  and  disinclined  to  respond  to  attentions. 
Hind  legs  possibly  a  little  less  stiff. 

January  12, 1905. — Slight  improvement  noted. 

January  17,  1905. — Dog  looks  badly.  Is  greatly  emaciated.  Indisposed 
to  move  and  hence  the  power  in  hind  legs  was  not  tested. 

January  18,  1905. — Great  emaciation. 


412  OCCLUSION  OF  AKTEEIES 

Autopsy. — Peritonaeal  cavity  normal.  Band  shimmers  through  a  perfectly 
normal-looking  peritonaeum.  No  trace  of  peritonaeal  or  other  scar  over 
band.  The  healing  about  the  band  is  the  most  absolutely  perfect  that  we 
have  as  yet  seen. 

With  a  syringe  connected  to  the  aorta  above  the  band  we  are  unable  to 
force  water  through  the  site  of  obstruction.  On  removing  the  band  we  find, 
to  our  surprise,  that  not  only  could  the  point  of  a  scissors  readily  be  passed 
through  the  constricted  part  but  that  the  aortic  wall  under  the  band  could 
be  so  perfectly  smoothed  out  that  not  a  trace  of  the  foldings  or  wrinklings 
of  the  lining  remained.  Nor  was  there  apparent  the  slightest  thinning  or 
alteration  in  the  wall  of  the  vessel  at  the  site  of  the  band.  We  have  not  as 
yet  had  the  time  to  complete  experiments  undertaken  with  a  view  to  account- 
ing for  the  difference  in  the  condition  of  the  aorta  at  the  site  of  constriction 
in  the  cases  (Nos.  27  and  28)  referred  to. 

Dog  No.  30. — Medium-sized  collie  bitch.  December  27, 1904.  Operation  I. 
Aluminium  band  tightened  until  the  pulse  was  greatly  reduced  but  not 
apparently  obliterated.  There  was  sufficient  pulse  just  prior  to  the  final 
tightening  to  give  a  faint  thrill. 

December  28,  1904. — Dog  convalescing  normally.  Uses  hind  legs  quite 
well.  No  definite  signs  of  weakness  in  them. 

January  7,  1905. — No  weakness  in  hind  legs. 

January  19, 1905. — Dog  very  well.  Femoral  pulse  not  yet  distinguishable. 

January  23,  1905. — Operation  II.  11  a.  m.  There  were  a  few  adhesions 
of  omentum  in  the  neighborhood  of  the  band,  which  prevented  the  metal 
from  shimmering  in  the  usual  manner  through  the  peritonaeum.  Pulse  below 
the  band  is  feeble  but  perfectly  definite.  When  the  pulse  just  above  the  band 
is  obliterated  with  the  finger  the  pulse  below  the  band  disappears.  We  con- 
cluded consequently  that  the  band  had  not  completely  closed  the  lumen  of 
the  aorta.  Ligation  with  heavy  black  silk  3  or  4  mm.  above  band.  Much  to 
our  astonishment  the  pulse,  easily  appreciable  by  finger,  reappeared  below 
the  band  in  less  than  30  seconds  after  the  aorta  was  ligated.  It  seems  almost 
inconceivable  that  a  ligature  applied  so  close  above  the  band  should  have  had 
such  a  marked  influence  on  the  pulse  below  it.  We  have  made  this  observa- 
tion in  a  number  of  cases  in  which  we  were  quite  sure  that  no  vessel  of  a  size 
to  be  appreciated  was  given  off  from  the  aorta  between  the  ligature  and 
the  band. 

The  almost  immediate  reappearance  of  the  pulse  after  the  application  of 
the  ligature  indicates  that  the  anastomotic  circulation  was  already  quite 
well  established,  for  a  pulse  large  enough  to  be  appreciated  by  the  finger 
has  not  been  observed  by  us  before  the  termination  of  the  operation,  after 
complete  closure  of  the  aorta  in  one  act.  We  have,  however,  noted  that 
within  a  minute  after  ligation  of  the  abdominal  aorta  a  faint  pulse  below 
the  ligature  can  be  seen  (not  felt),  provided  the  aorta  is  cut  open. 


BY  METAL  BANDS  413 

January  23,  1905. — 3  p.  m.  Dog  runs  about.  Weakness  of  hind  legs  not 
apparent. 

January  2^,  1905. — A  very  faint  femoral  pulse  can  be  felt  very  high  up 
on  the  femoral  arteries.  No  weakness  of  hind  legs. 

January  27 ',  1905. — Pulse  more  easily  felt  but  still  feeble. 

February  1,  1905. — Femoral  pulse  can  be  counted.  The  artery  is  not  full. 

February  20, 1905. — Artery  much  fuller.  Pulse  stronger.  Dog  quite  thin. 

March  10,  1905. — Femoral  pulse  still  small.  Dog  is  thin  but  looks  well. 
Ether  administered.  Abdomen  opened.  Small  indurated  area  about  the 
ligature  and  the  band.  A  definite  pulse  below  the  band  is  promptly  shut  off 
by  pressure  immediately  above  the  band  and  at  higher  points,  as  noted  in 
history  of  Dog  No.  6.  A  ligature  was  applied  about  3  cm.  above  the  band 
and  tests  for  a  pulse  below  the  band  were  made  for  three  minutes  but  it  had 
not  returned  in  this  period  of  time.  The  dog  was  then  killed.  Above  the 
ligature  the  aorta  was  entirely  occluded  in  a  conical  manner.  The  ligature 
lies  in  a  small  cavity  lined  with  granulations.  Below  the  band  the  aorta  is 
closed  off  by  a  small  transparent  film.  The  band  lies  in  a  connective  tissue 
cavity  and  contains  merely  a  film  of  opaque  secretion.  The  aortic  wall  under 
the  band  has  consequently  been  entirely  absorbed.  Between  the  two  cavities 
a  piece  of  aorta  13  mm.  in  length  is  felt  with  a  partly  organized  clot  which 
is  translucent  except  for  a  red  dot  about  1  mm.  broad,  in  its  center. 

It  is  evident  that  at  the  first  operation  I  was  probably  mistaken  in  believ- 
ing that  the  artery  was  not  obliterated  by  the  constricting  band.  It  would, 
a  priori,  seem  reasonable  to  presume  that  a  band  though  not  altogether 
occluding  the  artery,  might,  nevertheless,  so  greatly  interfere  with  the  cir- 
culation of  its  wall  as  to  lead  to  necrosis,  but  the  findings  in  Dog  No.  28 
would  seem  to  make  such  a  view  untenable.  It  seems,  however,  not  unlikely 
that  the  necrosis  of  the  wall  of  the  aorta  may  not  have  supervened  until  at 
the  second  operation  the  ligation  with  silk  a  few  millimetres  above  the  band 
was  made.  If  this  were  the  case  it  may  be  that  our  impression  that  the 
pulse  had  not  been  obliterated  by  the  band  at  the  first  operation  was  correct. 

Thoracic  Aorta  Partially  Occluded  by  Aluminium  Band. — Dog  No.  96. — 
Medium-sized  Newfoundland  bitch.  May  22,  1906.  Operation.  Assisted 
by  Drs.  Eichardson  and  Gilman.  Lungs  inflated  during  the  operation 
through  tracheotomy  tube.  Incision  through  seventh  interspace.  Eibs  sepa- 
rated as  usual  with  self -retaining  retractor.  Exposure  of  aorta  very  satis- 
factory. Aluminium  band,  thickness  No.  32,  width  6  mm.,  applied  just 
above  highest  point  of  diaphragm.  Band  was  tightened  until  a  continuous 
thrill  below  the  band  was  produced. 

May  21^,  1906. — Slight  stiffness  in  hind  legs. 
May  25, 1906. — Improving;  takes  milk.  Femoral  pulse  doubtful. 
May  27,  1906. — Cheerful;  runs  about  freely.   Percussion  reveals  no  tho- 
racic signs.   Chest  not  auscultated. 

June  1,  1906. — Dog  is  lively  and  well. 


414  OCCLUSION  OF  AETERIES 

June  3, 1906. — I  went  to  Boston. 

June  11,  1906. — On  my  return  from  Boston  today  dog  was  reported  well. 
I  did  not  visit  her. 

June  Ik,  1906. — On  visiting  dog  surprised  to  find  that  she  is  emaciated, 
low  spirited  and  very  weak.  Lies  in  corner  of  kennel  unless  aroused.  The 
keeper  states  that,  suddenly,  two  nights  ago  the  dog  became  paralyzed.  He 
assured  me  that  she  was  perfectly  well  the  preceding  day.  Has  made  no 
observations  as  to  her  stools,  urine  or  feeding.  I  placed  her  at  once  in  a 
separate  room  for  observation.  Find  that  she  can  raise  herself  on  hind  legs 
and  totter  about  with  hind  legs  stiff  and  held  apart.  Power  in  hind  legs 
quickly  becomes  completely  exhausted. 

June  15,  1906. — Better.  Takes  milk  and  eats  a  little. 

June  16,  1906. — Improving.  Has  some  appetite  and  a  stronger  gait.  The 
femoral  artery  is  fairly  full  but  a  pulse  is  not  palpable. 

June  18,  1906. — Stronger  and  in  fairly  good  spirits.  Is  as  lively  as  hind 
legs  permit  but  still  has  difficulty  in  getting  in  a  standing  position;  but 
when  balance  has  been  obtained  runs  about  quite  well,  but  for  a  few  moments 
only,  the  hind  legs  weakening  rapidly,  then  a  few  steps  alternating  with 
dragging.  Femoral  arteries  full  and  quite  tense  but  no  pulse  is  as  yet  dis- 
coverable although  carefully  palpated  for  by  several  observers. 

June  19,  1906. — At  times  there  seemed  to  me  to  be  a  faint  pulse  in  the 
femoral  artery.  Dog  much  livelier,  eats  better  and  gait  is  improved.  She 
still  experiences  considerable  difficulty  in  raising  herself  upon  her  hind  legs, 
and  after  running  five  or  six  seconds  flops  down  behind.  She  is  up  again 
immediately  and  again  collapses  as  to  hind  legs.  At  no  time  have  the  stools 
been  bloody  or  tarry.  There  has  been  no  evidence  either  of  retention  of  urine 
or  difficulty  in  micturition.  The  dog  is  to  be  kept  all  summer  under  careful 
observation. 

December  21,  1906.  Since  the  last  note  the  dog  has  been  well  but  is  still 
weak  in  the  hind  legs.  No  observations  of  especial  interest  were  made 
during  the  summer.  Careful  examination  by  Drs.  Sowers,  Watts  and  myself 
determine  that  a  femoral  pulse  is  present  but  not  easily  countable,  although 
it  is  now  seven  months  since  the  operation.  Only  the  lightest  pressure  of  the 
fingers  can  detect  this  femoral  pulse.  Ether  is  administered  and  the  dog 
brought  into  the  surgical  amphitheatre  for  demonstration  to  the  class.  The 
over-pressure  box  of  Drs.  Follis  and  Fisher  was  successfully  employed 
throughout  the  observations  which  follow.  On  opening  the  chest  the  left 
lung  and  pleura  were  normal.  The  band  is  clearly  seen  shimmering  through 
the  thin  and  normal-looking  pleura  covering  it.  A  very  pronounced  thrill 
is  felt  below  the  band  on  the  thoracic  aorta,  just  as  at  the  termination  of 
the  first  operation,  hence  our  belief  that  the  artery  had  suddenly  closed  about 
three  weeks  after  the  first  operation  and  during  my  absence  in  Boston  is 
proved  to  be  incorrect.  Dr.  Percy  M.  Dawson  then  made  the  following  obser- 
vations upon  the  blood  pressure  in  the  carotid  and  femoral  arteries. 


BY  METAL  BANDS  415 

"  Upon  the  circulation  of  this  animal  observations  were  made  in  the 
physiologic  laboratory  and  were  reported  as  follows : 

Maximum  pressure    Mean  pressure        Minimum  pressure      Pulse  pressure 
Femoral  116  96  88  28 

Carotid  160  113  83  77 

"  These  figures  should  be  compared  with  values  obtained  in  normal  ani- 
mals," namely, 

Femoral  188  120  95  93 

Carotid  162  122  103  49 

"  The  pressure  curves  were  also  obtained  and  showed  a  total  disappear- 
ance of  the  dicrotic  elevation  from  the  femoral  pulse  whereas  in  normal  ani- 
mals the  dicrotic  is  more  marked  in  the  femoral  than  in  the  carotid  artery 
so  that  hyperdicrotism  is  more  readily  obtained  in  the  former  than  in  the 
latter.13 

"  All  these  changes  are  to  be  attributed  to  the  constriction  due  to  the  band 
and  are  in  complete  accord  with  the  unpublished  experiments  performed  in 
this  laboratory  in  which  the  aorta  was  partially  occluded  for  the  purpose 
of  studying  the  relation  of  the  carotid  and  femoral  pulses. 

"  Considerable  variations  occur  in  the  velocity  of  the  pulse  wave  in  differ- 
ent dogs.  Nevertheless  it  is  safe  to  say  that  a  velocity  of  only  556  cm.  per 
second  as  was  found  in  this  animal,  owes  its  small  value  to  the  aortic 
constriction." 

Dr.  Bichardson  and  I,  by  the  Huertle  method  with  hypodermic  needle, 
observed,  much  to  our  surprise,  that  whereas  the  manometer  registered 
126  mm.  above  the  band,  it  registered  only  94  below  it.  It  seems  remarkable 
that  after  so  long  a  period  (approximately  seven  months)  there  should  be 
such  a  difference  in  the  blood  pressure  above  and  below  the  band.  Just 
before  death  the  aorta  was  completely  divided  below  the  band  to  determine 
the  degree  of  patency  of  this  vessel  at  the  constricted  point.  The  heart 
pumped  through  the  band  a  small  stream  as  large,  perhaps,  as  that  furnished 
by  the  human  radial  artery. 

Autopsy. — There  is  a  very  great  difference  in  the  size  and  thickness  of 
the  thoracic  aorta  above  and  below  the  band.  The  wall  of  the  artery  above 
the  band  appears  to  be  twice  as  thick  and  much  stiffer  than  the  arterial  wall 
below  it.  There  is  also  great  dilation  of  the  artery  above  the  band.  There 
are  no  visible  calcareous  plaques.  On  cutting  through  the  artery  and  band 
in  the  usual  way,  the  probe  point  of  a  scissors  being  passed  into  the  lumen 
of  the  vessel,  there  is  found  to  be  no  adhesion  between  the  folded  surfaces 
although,  until  the  artery  is  spread  quite  flat,  the  foldings  and  creasings  of 
the  intima  are  evident.  Were  it  not  for  the  presence  of  the  band  which 
reveals  its  form  from  within  by  pressure  on  the  wall  of  the  artery  from 

12  Amer.  Jour,  of  Physiol.,  1906,  xv,  244. 

13  Amer.  Med.,  1906,  i,  152. 


416  OCCLUSION  OF  ARTEKIES  BY  METAL  BANDS 

without  it  might  be  difficult  if  not  impossible  to  determine  with  the  naked 
eye  differences  so  far  as  the  free  surface  of  the  intima  is  concerned,  below 
and  beneath  the  band.  The  lining  of  the  aorta  under  the  metal  seems  per- 
fectly normal,  as  indeed  does  the  entire  thickness  of  the  arterial  wall.  The 
spinal  cord  was  excised  by  Dr.  Gilman  in  my  presence.  As  to  the  extra- 
dural fat  formation  in  this  case  a  report  will  be  made  later. 

EXPLANATION  OF  PLATES. 
Plate  XXVIII. 

1.  Drawn  in  1905.  The  original  band  roller  in  the  act  of  curling  a  metal  strip 
about  an  artery;  a,  the  tip  of  the  driving  blade  enlarged;  b,  the  metal  strip;  c,  the 
band  slightly  tightened  with  the  fingers  as  when  a  degree  of  incomplete  occlusion 
is  desired.  The  proportions  depicted  are  those  observed  at  the  time  the  drawing  was 
made.  We  should  now  regard  the  length  of  the  metal  strip  as  about  one-third  too 
great  for  its  width  as  well  as  for  the  size  of  the  artery  represented. 

2.  The  improved  band  roller — the  size  usually  employed  in  the  experimental  work. 
The  instrument  shown  in  full  length  is  unloaded.  In  the  abbreviated  cut  the  band 
is  about  to  be  expelled  from  the  roller.  This  band  is  broad  enough  for  the  abdominal 
aorta  in  man,  and  the  diameter  of  the  circle  is  too  short  for  a  vessel  requiring 
such  a  broad  band. 

Plate  XXIX. 

1.  Aorta  of  dog  after  partial  occlusion  by  band  for  one  month.  The  band  (b), 
in  outline,  is  seen  through  the  vessel's  wall.  2.  Aorta  of  Dog  27  converted  into  a 
solid  cylinder  (a),  the  band  (6)  having  embraced  the  artery  for  three  and  one-half 
months. 

3  and  4.  An  aorta  about  which  a  partially  occluding  ligature  of  silk  had  been 
placed.  In  4,  the  wall  of  the  artery  is  divided  anteriorly  only  enough  to  expose  the 
diaphragm  formed  in  the  track  of  the  ligature  and  perforated  by  two  holes,  a  and  a'. 
The  silk  ligature,  at  b,  is  more  plainly  seen  in  4,  in  which  the  diaphragm  has  been 
divided  as  far  as  and  into  the  anterior  perforation. 

Plate  XXX. 

The  kidneys  of  a  dog  six  months  after  the  application  of  an  occluding  band  to 
the  renal  artery  of  one  of  them.  The  band,  spread  out,  lies  in  situ  under  the  right 
renal  artery  which  had  become  converted  into  a  solid  cylinder  at  this  point,  but  was 
collapsed  both  proximal  and  distal  to  the  occluding  metal.  Contrast  the  renal  ar- 
teries of  the  two  sides. 


PLATE   XXVIII 


PLATE  XXIX 


Natural  size 
l.  2. 


dk^  •  eUr*-*.^- 


PLATE   XXX 


PARTIAL  OCCLUSION  OF  THE  THORACIC  AND  ABDOMINAL 

AORTAS  BY  BANDS  OF  FRESH  AORTA  AND 

OF  FASCIA  LATA  ' 

Ligation  of  the  human  abdominal  aorta  has  been  made  nineteen  or 
twenty  times  and  always  with  fatal  result. 

Dubois,  Assalini,  Bujalsky,  Cooper,  Keen,  and  perhaps  others,  attempted 
to  occlude  the  abdominal  aorta  gradually  by  means  of  cleverly  devised  in- 
struments which,  carrying  snares  of  silk,  metal,  or  catgut,  might  be  tight- 
ened or  loosened  at  will.  The  instruments  traversed  the  abdominal  wall 
and  hence  infection  was  a  complication  common  to  all  of  the  methods  and 
defeated  the  plans  of  the  operators. 

In  190-1,  assisted  by  Dr.  W.  F.  Sowers,  I  began  a  series  of  experiments 
on  dogs  in  the  hope  of  finding  a  safe  method  of  occluding  the  aorta  and 
curing  aortic  aneurism.  Bands  of  silver  and  aluminum  curled  about  the 
aorta  by  an  instrument  constructed  for  this  purpose  were  rolled  tighter 
by  the  fingers  until  the  desired  degree  of  occlusion  of  this  vessel  was  obtained. 
The  abdominal  wounds  were  closed  with  the  expectation  that  they  would 
have  to  be  reopened  one  or  more  times  for  the  purpose  of  progressively 
occluding  the  lumen  of  the  artery.  But  in  the  course  of  our  experiments 
we  had  opportunities  to  make  trial  in  the  human  subject  of  partially  occlud- 
ing bands  on  other  arteries  (innominate,  subclavian,  carotid,  femoral,  pop- 
liteal) whose  blood  streams  in  some  instances  it  seemed  unsafe  to  cut  off 
suddenly  and  completely,  and  found  that  occlusion  of  an  artery,  carried  to 
the  point  of  obliterating  the  pulse,  usually  sufficed  to  cure  the  aneurism, 
possibly  quite  as  surely  as  might  have  been  expected  of  total  occlusion. 
Hence,  tentatively,  I  abandoned  the  idea  of  progressive  closure  of  the  aorta, 
determining,  instead,  to  obliterate  the  lumen  of  this  vessel,  in  the  attempt 
to  cure  its  aneurism,  to  an  extent  which  we  had  found  quite  safe  in  the  dog. 

I  have  applied  an  aluminum  band  to  the  human  aorta  four  times;  twice 
in  one  subject  and  twice  with  promising  results  so  far  as  the  cure  of  the 
aneurism  is  concerned.   But  the  experimental  work  on  animals  had  led  me 

Presented  before  the  American  Surgical  Association,  Washington,  D.  C,  May 
7,  1913. 

Also  presented  at  the  Society  of  Experimental  Biology  and  Medicine,  52nd. 
Meeting,  N.  Y.,  February  19,  1913. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1913,  xxxi,  218-222.    (Reprinted.) 

Also:    Ann.  Surg.,  Phila.,  1913,  lviii.  183-187. 

Also:    (Abstr.)  Proc.  Soc.  Exper.  Biol.  &  Med.,  N.  Y.,  1912-1913,  x,  113-116. 
28  417 


418  PARTIAL  OCCLUSION  OF  AORTA 

to  expect  that  ultimately  the  metal  bands  must  cut  through  the  artery 
because  in  cases  observed  for  seven  months  or  less  the  frail  of  the  aorta  had 
become  atrophied  to  the  thinness  of  paper  and  there  was  no  adhesion  between 
the  infolded,,  attenuated  surfaces.  That  my  fears  were  well  founded  was 
proved  by  an  experience  in  Europe,  about  eighteen  months  ago.  The  patient 
was  an  aged  woman  with  dilated  and  badly  functioning  heart.  The  large 
aortic  aneurism  was  well  located  for  the  placing  of  a  band  which  was  applied 
just  below  the  renal  vessels.  Within  a  few  days  the  aneurism,  which  before 
operation  was  distinctly  visible  from  the  seats  of  the  operating  amphi- 
theatre, was  barely  discernible  at  the  bedside,  and  at  the  end  of  six  weeks 
had  disappeared  so  completely  that  the  patient  was  discharged  apparently 
cured.  But,  walking  out  of  the  door  of  the  hospital  she  was  seized  with  a 
pain  and  returned  to  her  bed.  The  following  morning  she  died  from  haemor- 
rhage. The  aorta  had  ruptured  at  the  site  of  the  band,  but  the  aneurism 
was  found  to  be  nearly  cured. 

Stimulated  by  the  result  in  this  case  to  further  experimentation,  it 
occurred  to  me  to  test  the  behavior  of  cuffs  and  spiral  strips  of  the  fresh 
aorta  of  one  dog  when  wound  about  the  aorta  of  another.  So  on  April  29, 
1912, 1  operated  upon  two  dogs,  partially  occluding  the  aorta  of  one  of  them 
with  a  spiral  aortic  band  and  of  the  other  with  a  cuff  cut  from  the  same 
vessel.  Strips  of  aorta  were  employed  rather  than  of  fascia  lata,  for  example, 
because  I  hoped  that  the  elastic  tissue,  in  case  it  did  not  endure  might,  at 
least,  serve  its  purpose  for  a  time  sufficient  to  cure  an  aneurism. 

At  the  end  of  two  months  one  of  the  dogs  was  killed  and  I  was  pleased 
to  find  that  the  cuff  which  had  been  used  in  this  experiment  was  apparently 
organized  and  had  not  stretched  to  any  appreciable  extent.  Above  the  cuff 
the  aortic  pulse  was  forcible,  but  below  the  constriction  it  was  very  feeble, 
though  countable  and  accompanied  by  a  thrill. 

The  other  dog  operated  upon  at  the  same  time  and  in  the  same  manner, 
except  that  a  spiral  band  of  aorta  instead  of  a  cuff  had  been  employed,  died 
(cause  of  death  unascertained)  about  three  weeks  after  the  operation. 
In  this  instance  the  aorta  had  been  almost  completely  occluded  by  the  spiral 
aortic  strip.  The  welt-like  band  had  not  stretched  and  seemed  to  be  organ- 
ized. The  aorta,  on  being  split  longitudinally,  was  seen  to  be  greatly 
wrinkled  and  almost  occluded  at  the  site  of  the  band.  Sections  of  the  speci- 
mens indicated  that  the  elastic  coats  of  the  bands  as  well  as  of  the  included 
artery  were  intact.'  During  the  present  winter  I  have  made  about  twenty-five 

1  These  observations  were  briefly  reported  a  year  ago  in  a  footnote  to  an  article 
entitled  "  The  Effect  of  Ligation  of  the  Common  Hiac  Artery  on  the  Circulation  and 
Function  of  the  Lower  Extremity,"  Johns  Hopkins  Hospital  Bulletin,  July,   1912, 

]:   .'17. 


BY  TISSUE  BANDS  419 

similar  experiments  with  encouraging  results.  We  have  learned,  however, 
that  whereas  the  spiral  bands  seem  to  be  perfectly  safe,  there  is  danger  in 
the  employment  of  the  cuffs.  In  two  instances  of  twelve  or  more  experiments, 
one  of  the  mattress  sutures  taken  to  hold  the  flaps  of  the  cuffs  together  cut 
part  way  through  the  cuffs  and  thus,  being  brought  in  contact  with  the 
aortic  wall,  wore  a  minute  hole  in  the  vessel  through  which  the  animal  bled 
to  death.  Such  an  accident  can  hardly  happen  with  the  employment  of  the 
spiral  strip,  for  not  only  is  the  strain  on  the  stitches  very  slight  when  this 
form  of  band  is  used,  but  even  if  it  were  so  great  that  a  thread  might  cut 
through  the  spiral  at  any  point,  it  could  hardly  be  brought  to  bear  upon  the 
aorta  in  such  a  way  as  to  wear  into  its  wall. 

To  each  end  of  the  band  of  fresh  tissue  a  narrow  tape  is  sewed  to  facilitate 
the  manipulation  of  the  transplant,  which  is  wound  twice  about  the  aorta. 
When  one  or  two  stitches  have  been  taken  at  one  end  to  hold  the  contiguous 
edges  of  the  spiral  together  at  this  point,  the  other  end  of  the  strip  is  pulled 
upon  until  the  aorta  is  occluded  to  a  little  more  than  the  desired  amount, 
and  then  two  additional  stitches  are  taken  to  maintain  the  constriction. 

Within  the  past  few  weeks  I  have  examined  the  bands  of  aorta,  fascia  lata, 
and  chromicized  submucosa  which  had  been  wound  about  the  aorta  last 
autumn  and  winter.  In  two  instances  in  which  considerable  constriction  of 
the  aorta  had  been  made  about  four  months  previously,  kyniographic  trac- 
ings of  the  blood  pressure  in  the  femoral  and  carotid  arteries  were  made  in 
the  physiological  laboratory  by  Professor  Howell  and  Mr.  Cecil.  To  our 
surprise  there  was  no  diminution  in  the  femoral  pressure,  and  on  investi- 
gating the  band  it  was  found  in  each  instance  to  have  relaxed  and  to  have 
been  partially  absorbed. 

In  dogs  operated  upon  as  long  as  seven  months  ago  there  was  considerable 
absorption  of  the  band ;  and  in  one  instance  only  a  trace  of  it  remained.  One 
spiral  band  which  had  been  applied  so  as  to  make  almost  total  occlusion  seven 
months  before  seemed  microscopically  to  be  well  preserved,  but  it  no  longer 
constricted  the  aorta,  the  lumen  of  which  was  completely  restored,  and  whose 
underlying  wall  was  apparently  normal. 

These  findings  do  not  discourage  me,  for  if  the  constriction  can  be  main- 
tained for  two  months  or  even  one  month,  it  might  effect  the  cure  of  an 
aneurism,  and  if  not,  a  totally  occluding  ligature  might  perhaps,  after  such 
lapse  of  time,  be  applied  without  great  risk,  and  possibly  the  aneurism  in 
some  cases  might  then  be  excised.  The  desirability  of  transplanting,  when 
feasible,  a  segment  of  vessel  must  always  be  borne  in  mind. 

About  three  weeks  ago  I  received  from  Dr.  Francesco  Nassetti  a  reprint  of 
a  paper  by  him  entitled  "  Awolgimento  di  vasi  Sanguigni  con  lembi  liberi 
di  aponeurosi,"  and  published  April  26, 1912,  in  the  Atti  della  R.  Academia 


420  PARTIAL  OCCLUSION  OF  AORTA 

dei  Fisiocritici  in  Siena.  Dr.  Nassetti's  experiments  were  made  in  the 
Istituto  di  Pathalogia  Speciale  Chirurgica  della  E.  Universita  di  Siena, 
which  is  under  the  direction  of  Prof.  A.  Salomoni.  His  first  experiment 
(a  band  of  fascia  about  the  carotid  artery)  antedates  mine  by  fifty-six  days, 
and  his  article  appeared  about  three  months  before  the  publication  by  me 
of  a  brief  account  of  my  first  experiments  with  spiral  strips  of  aorta 
(Johns  Hopkins  Hospital  Bulletin,  July,  1912,  p.  217).  Dr.  Nassetti  has 
written  on  the  cover  of  the  reprint  which  he  kindly  sent  me  that  his  article 
appeared  in  print  April  26,  1912.  My  first  experiment  with  the  bands  of 
fresh  aortic  wall  was  made  April  29,  1912,  three  days  after  the  publication 
of  Nassetti's  report.  Hence  the  credit  for  the  idea  of  constricting  blood 
vessels  with  bands  of  fresh  tissue  belongs,  I  am  happy  to  say,  to  Italy,  the 
country  of  the  famous  surgeon,  Luigi  Porta,  who  was,  I  think,  the  first  to 
attempt  the  partial  occlusion  of  an  artery.  I  have  the  impression  that  Porta 
used  for  this  purpose  a  strip  of  diachylon  plaster. 


DER  PARTIELLE  VERSCHLUSS  GROSSER  ARTERIES ' 

Die  Unterbinclung  der  Bauchaorta  beim  Menschen  ist  zwanzig  Mai  oder 
noch  ofter  ausgefiihrt  worden  und  zwar  immer  mit  todlichem  Ausgange. 
Dubois,  Assalini,  Bujalsky,  Cooper,  Keen  und  andere  versuchten  die  Bauch- 
aorta unter  Anwendung  klug  ausgedachter  Instrumente  schrittweise  zu 
verlegen,  indem  sie  Schlingen  von  Draht,  Seide  oder  Catgut  herumfuhrten 
und  diese,  nach  Belieben,  fester  oder  loser  anlegten.  Da  aber  diese  Instru- 
mente aus  dem  Bauche  herausragten,  so  war  die  Infektion  von  bier  aus  die 
unvermeidliche  Komplikation  aller  dieser  Methoden  und  sie  war  es,  die  die 
Plane  der  Operateure  zu  nichte  machte. 

Im  Jahre  1904  unternahm  ich  eine  Reihe  von  Versuchen  an  Hunden,  in 
der  Hoffnung  eine  ungefahrliche  Methode,  die  Aorta  zu  verlegen  und  das 
Aortenaneurysma  zu  heilen,  ausarbeiten  zu  konnen.  Mit  einem  eigens  zu 
diesem  Zwecke  konstruierten  Instrumente  (s.  Platte  XXVIII,  2,  und 
Platte  XXXI)  ringelte  ich  Silber-  und  Aluminiumbander  um  die  Aorta 
und  rollte  sie  unter  den  Fingern  noch  starker  an,  bis  der  gewiinschte  Grad 
des  Gefassverschlusses  erreicht  war.  Die  Bauchwunde  wurde  geschlossen  in 
der  Erwartung,  das  Abdomen  ein  oder  zweimal  wieder  zu  eroffnen,  um  das 
Gefasslumen  fortgesetzt  weiter  zu  verengern.  Im  Verlaufe  unserer  Experi- 
mente  hatten  wir  Gelegenheit,  am  Menschen  den  partiellen  Bandverschluss 
zu  versuchen  und  zwar  an  anderen  Arterien  (z.  B.  der  A.  anonyma,  sub- 
clavia,  carotis,  femoralis,  poplitea),  deren  Blutstrom  plotzlich  und  vollstan- 
dig  zu  unterbrechen  gefahrlich  erschien. 

Wir  fanden,  dass  der  Gefassverschluss  bis  zu  dem  Momente,  wo  der  Puis 
verschwindet,  manchesmal  ausreichte,  um  das  Aneurysma  zu  heilen,  mog- 
licherweise  fast  so  sicher  wie  man  es  in  denselben  Fallen  beim  Totalverschluss 
hatte  erwarten  konnen.  Von  hier  an  anderte  ich  deshalb  den  Plan  des  fort- 
gesetzten  Aortenverschlusses.  Die  Idee  einer  progressiven  Gefasslumenver- 
legung  aufgebend,  beschloss  ich,  die  Aorta  auf  einmal  so  weit  zu  verschlies- 
sen,  wie  wir  es  ohne  Gefahr  tun  konnten. 

1  Auszugsweise  vorgetragen  am  2.  Sitzungstage  des  XLIII.  Kongresses  der  Deut- 
schen  Gesellschaft  fiir  Chirurgie,  16.  April  1914. 

Presented  at  the  43rd.  Kongresses  der  deutschen  Gesellschaft  fiir  Chirurgie.  Berlin, 
April  16,  1914. 

Archiv.  f.  klin.  Chir.,  Berl.,  1914,  cv,  580-599.    (Reprinted.) 

Aho:    Verhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  Berl.,  1914,  xliii,  2.  Teil,  349-367. 

421 


422  DER  PARTIELLE  VERSCHLUSS 

Viermal  habe  ich  bei  der  Aorta  des  Menschen  eine  Aluminiumbandrolle 
verwendet,  zweimal  mit  aussichtsreichem  Erfolge,  soweit  es  allein  die  Heil- 
ung  des  Aneurysmas  betraf. 

Die  experimentelle  TTntersuchung  an  Tieren  aber  hat  mich  bewogen  abzu- 
warten,  da  schliesslich  die  Metallbandrolle  die  Arterie  durchdringen  musste. 
Denn  in  Fallen,  die  ich  sieben  Monate  oder  langere  Zeit  beobachtet  hatte, 
war  die  Aortenwand  bis  zu  Papierdiinne  atrophisch  geworden  (s.  Platte 
XXIX,  1  und  2),  nnd  nirgends  waren  an  der  gefalteten  und  verdiinnten 
inneren  Oberflache  Adhasionen  vorhanden.  Dass  meine  Befurchtungen 
wohl  begriindet  waren,  ist  durch  einen  Versuch  in  der  Klinik  von 
Prof.  Kocher  vor  drei  Jahren  bewiesen  worden.  Die  Patientin  war  eine 
bejahrte  Frau  mit  dilatiertem  und  unregelmassig  arbeitendem  Herzen. 
Das  grosse  Aortenaneurysma  war  sehr  geeignet  fiir  die  Anlegung  des  Bandes, 
welches  unmittelbar  unter  den  Nierenarterien  herumgelegt  wurde.  Inner- 
halb  weniger  Tage  war  das  Anenrysma,  das  vor  der  Operation  von  den 
Sitzen  des  amphitheatralischen  Operationssaales  deutlich  sichtbar  gewesen 
war,  nur  noch  am  Bett  zu  erkennen,  und  nach  Ablauf  von  sechs  Wochen 
war  es  so  vollkommen  verschwunden,  dass  die  Patientin,  scheinbar  fast 
geheilt,  entlassen  werden  sollte.  Allein  in  dem  Momente,  wo  sie  die  Schwelle 
des  Krankenhauses  uberschreiten  wollte,  wurde  sie  von  heftigem  Schmerze 
gepackt  und  kehrte  zu  ihrem  Bett  zurlick.  Am  nachsten  Morgen  starb  sie  an 
innerer  Verblutung.  Die  Aorta  war  geborsten  an  der  Stelle,  wo  das  Band 
lag;  das  Aneurysma  aber  wurde  um  vielleicht  drei  Viertel  verkleinert 
gefunden. 

Durch  das  Resultat  in  diesen  Fallen  zu  weiteren  Versuchen  ermutigt, 
kam  ich  auf  den  Gedanken,  Manschetten  und  Spiralstreifen  frischer  Hunde- 
aorta  auszuprobieren,  welche  rings  um  die  Aorta  eines  anderen  Hundes  ge- 
wunden  wurden.  Nach  diesem  Prinzip  operierte  ich  am  29.  April  1912 
zwei  Hunde ;  bei  dem  einen  verschloss  ich  die  Aorta  unvollstandig  durch  ein 
spiraliges  Band,  bei  dem  anderen  mit  einem  manschettenartigen  Streifen, 
der  aus  der  Aorta  eines  dritten  Hundes  geschnitten  war.  Streifen  aus  der 
Aorta  wurden  lieber  verwendet  als  z.  B.  Fascia  lata,  weil  ich  hoffte,  dass  das 
elastische  Gewebe  fiir  den  Fall,  dass  es  nicht  dauernd  erhalten  bliebe,  doch 
wenigstens  fiir  einige  Zeit  den  Zweck  erfiillen  mochte,  lange  genug  vielleicht, 
um  das  Aneurysma  zu  heilen. 

Nach  Verlauf  von  zwei  Monaten  wurde  der  eine  von  den  Hunden  getotet, 
und  ich  war  erfreut  zu  finden,  dass  die  bei  diesem  Versuche  verwendete 
Aortenmanschette  vollstandig  organisiert  zu  sein  schien  und  sich  nicht 
nachweisbar  ausgedehnt  hatte.  Oberhalb  des  Bandes  war  die  Aortenpulsa- 
tion  kriiftig,  dagogen  unterhalb  der  Umschnurung  nur  schwach,  doch  ziihl- 
bar,  und  jedesmal  von  einem  Schwirren  begleitet. 


PLATE   XXXI 


L 


n 


5 


■i 


Das  Bandrollinstrument  in  vier  verschiedenen  Grossen. 
Vor  jedem  liegt  ein  Metallring,  dessen  Grosse  derjenigen 
des  betreffenden  Instruments  entspricht.  Grosse  a  findet 
Verwendung  an  der  Aorta;  Grosse  b  an  der  Carotis 
der  Iliaca  Externa.  Femoralis,  Poplitea ;  Grosse  c  und 
d  bei  Tierexperimenten. 


GROSSER  ARTERIEX  423 

Der  andere,  zu  derselben  Zeit  und  nach  demselben  Prinzip  operierte 
Hund,  ausgenommen,  dass  ein  Spiralband  von  Aortengewebe  anstatt  einer 
Manschette  desselben  angewendet  worden  war,  starb  spontan  etwa  drei 
Wochen  nach  der  Operation.  Bei  diesem  Tier  war  die  Aorta  fast  vollstandig 
durch  das  spiralige  Band  verschlossen.  Das  Band  hatte  nicht  nachgegeben 
und  schien  organisiert  zu  sein.  Anf  dem  Langsschnitt  war  zu  erkennen,  dass 
die  Aorta  stark  gefaltet  und  an  der  Stelle,  wo  das  Band  lag,  beinahe  verlegt 
war.  Die  mikroskopische  Untersuchung  des  Praparates  stellte  fest,  dass  die 
elastischen  Fasern  sowohl  des  umgelegten  Aortenbandes,  wie  auch  der  um- 
schniirten  Aorta  selber  iiberall  beinahe  intakt  waren. 

Wahrend  des  "Winters  1912-1913  habe  ich  etwa  25  ahnliche  Versuche 
angestellt  mit  durchaus  ermutigenden  Resultaten.  Folgendes  haben  wir 
aber  gelernt.  "Wahrend  die  Spiralbander  wahrscheinlich  vollkommen  unge- 
fahrlich  sind,  ist  vor  der  Anwendung  von  Manschetten  zu  warnen. 

Zweimal  bei  12  oder  mehr  Versuchstieren  schnitt  eine  der  Matratzennahte, 
die  zur  Fixation  der  Mannschetten  benutzt  worden  waren,  durch  die  Man- 
schetten hindurch,  wurde  somit  in  Kontakt  gebracht  mit  der  Aortenwand 
und  rieb  ein  kleines  Loch  in  die  Aorta,  durch  welches  sich  das  Tier  todlich 
verblutete.  Solch  ein  Ungliicksfall  kann  kaum  passieren,  wenn  man  Spiral- 
streif  en  nimmt.  Denn  meist  ist  die  Spannung  an  den  Xahtstellen  sehr  unbe- 
deutend  bei  Yerwendung  dieser  Bandstreifen.  Aber,  selbst  den  Fall  gesetzt, 
sie  ware  so  gross,  dass  die  Faden  die  Spirale  an  einer  Stelle  durchschnitten, 
so  konnten  diese  kaum  nach  dem  beschriebenen  Modus  auf  die  Aorta  gebracht 
werden  und  das  Gefass  usurieren. 

Techxik  bei  dee  Axleguxg  dee  Spikatye 

Jedes  Ende  des  Bandes  von  frischem  Gewebe  wird  zur  leichteren  Hand- 
habung  des  Transplantates,  das  zweimal  urn  die  Aorta  gewickelt  wird,  mit 
einem  breiten  Zwirnsfaden  versehen.  Wenn  zwei  Xahte  an  dem  einen  Ende 
gelegt  sind,  ran  die  anstossenden  Bander  der  Spirale  an  einem  Punkte  mit 
einander  zu  fixieren,  wird  das  andere  Ende  des  Streifens  angezogen,  bis  die 
Aorta  um  den  gewimschten  Grad  verschlossen  ist,  dann  wird  durch  zwei 
weitere  Xahte  die  Umschniirung  aufrecht  erhalten. 

Vor  anderthalb  Jahren  untersuchte  ich  die  Spiralbander  der  Aorta,  Fascia 
lata  und  Chromcatgut,  die  ich  um  die  Aorta  von  Hunden  gewunden  und 
bestimmte  Zeitperioden,  zwei  bis  sieben  Monate,  liegen  gelassen  hatte.  Bei 
zwei  Hunden,  bei  denen  die  vorlaufige  Umschniirung  der  Aorta  vor  4  Mon- 
aten  gemacht  worden  war,  wurde  mit  dem  Kymographion  die  Blutdruck- 
kurve  an  der  Femoralis  und  der  Carotis  im  Physiologischen  Institute  von 
Professor  Howell  und  Dr.  Cecil  aufgezeichnet.  Zu  unserer  Ueberraschung 
bestand  keine  Herabsetzung  des  Blutdruckes  in  der  Femoralis  gegeniiber 


424  DER  PARTIELLE  VERSCHLUSS 

dem  in  der  Carotis.  Die  Priifung  der  Bander  wurde  vorgenommen  und  es 
zeigte  sich  bei  beiden  Tieren,  dass  nicht  nur  die  Bander  nachgegeben  hatten, 
sondern  mehr  oder  weniger  resorbiert  waren.  Von  einem  Bande,  das  7 
Monate  vor  Totung  des  Hundes  umgelegt  worden  war,  blieb  nur  eine  Spur 
zuriick.  Ein  Spiralband,  das  zur  Erzeugung  eines  fast  vollkommenen  Ver- 
schlusses  7  Monate  vorher  umgelegt  worden  war,  erschien  makroskopisch 
gut  erhalten  zu  sein.  Aber  es  hatte  die  Aorta  nicht  mehr  komprimiert;  ihr 
Lumen  war  vollkommen  wieder  hergestellt  und  die  Wand  war  scheinbar 
normal. 

Diese  Befunde  indessen  sollen  uns  nicht  entmutigen,  denn  wenn  die 
Umschniirung  fur  sechs  Wochen  oder  zwei  Monate  erhalten  werden  kann, 
so  konnte  dieses  moglicherweise  ausreichen,  um  die  Heilung  des  Aneurysmas 
herbeizuf iihren ;  und  wenn  nicht,  ein  totaler  Verschluss  des  Rohres  durch 
die  Ligatur  kann  nach  dieser  Zeitspanne  mit  geringerem  Risiko  ausgefuhrt 
werden. 

Vor  etwa  einem  Jahre  erhielt  ich  von  Dr.  Francesco  Nasetti  einen  Sepa- 
ratabzug  seiner  Arbeit,  betitelt:  „Avvolgimento  di  vasi  sanguigni  con 
lembi  liberi  di  aponeurosi",  die  am  26.  April  1912  in  der  Atti  della  R. 
Accademia  dei  Fisiocritici  in  Siena  publiciert  ist.  Dr.  Nasetti's  Untersuch- 
ungen  wurden  im  Institute  der  speziellen  pathologischen  Chirurgie  der 
Universitat  Siena  (Dir.  Prof.  A.  Salomoni)  angestellt.  Mein  erstes  Ex- 
periment mit  Streifen  frischer  Aortenwand  wurde  am  29.  April  1912,  drei 
Tage  nach  der  Publikation  Nassetti's  gemacht.  Indessen  gehbrt  das  Anrecht 
dieser  Idee,  Blutgefasse  mit  frischen  Gewebsbandern  zu  umschnuren,  Italien, 
dem  Vaterlande  des  hervorragenden  Chirurgen  Luigi  Porta,  der  soviel  ich 
weiss,  der  erste  war,  der  den  partiellen  Verschluss  von  Arterien  versucht  hat. 

Da  der  partielle  Verschluss  der  Aorta  bei  Anwendung  lebenden  Gewebes 
sich  nicht  langer  als  nur  wenige  Wochen  erhalt,  und  da  ferner  die  Wanda- 
trophie  der  Aorta  mit  ihrer  drohenden  Gefahr  unter  dem  Metallband  unver- 
meidlich  ist,  habe  ich  im  vergangenen  Winter  mit  Spiralbandern  von  Leinen 
Versuche  gemacht.  Ich  hoffte,  dass  das  Granulationsgewebe  moglicherweise 
in  die  Maschen  des  Bandes  eindringen  und  dieses  bis  zu  einem  gewissen 
Grade  fur  einen  langeren  Zeitraum  dem  Arterienrohr  einverleiben  konnte. 
Mein  Wunsch  ging  dahin,  ein  Band  mit  moglichst  weiten  Oeffnungen 
anzuwenden,  und  so  wurde  mein  erster  Versuch  mit  einem  Gazestreifen 
gemacht,  der  nach  auf  ein  Stuck  frische  Fascia  lata  aufgenaht  wurde. 
Diese  Kombination  von  Gaze  und  Fascia  lata  wurde  in  spiraligen  Touren 
um  die  Aorta  gewunden  und  zwar  so,  dass  die  Gaze  auf  die  Gefasswand  zu 
liegen  kam.  Innerhalb  zweier  Tage  hatte  einer  von  den  feinen  Gazefaden 
die  Aorta  durchschnitten  und  das  Tier  hatte  sich  todlich  verblutet.  Sodann 
wurde  die  allerfeinste  Seidenborte  versucht.    Sobald  diese  aber  durch  die 


GROSSES  ARTERIEN  425 

Gewebsfliissigkeit  feucht  geworden  war  und  dann  angezogen  wurde,  drehte 
sie  sich  zu  einem  feinen  Strang  zusammen  und  konnte  dann  nicht  mehr 
flach  um  das  Gefass  gelegt  werden.  Bander  dagegen,  die  in  alkoholischer 
Schellacklosung  getrankt  und  dann  getrocknet  waren,  liessen  sich  in  be- 
f  riedigender  Weise  als  Spirale  verwenden.  Wir  wandten  auch  leinene  Spiral- 
bander  von  grosserer  Starke  an,  und  haben  die  Absicht,  mehrere  dieser  so 
behandelter  Tiere  ein  Jahr  oder  noch  langer  zu  beobachten.  Einige  von 
ihnen  wurden  im  Oktober  1913  operiert  und  sie  sind  allesamt  in  gutem 
Zustande.  Drei  Hunde,  bei  denen  ich  diese  starkeren  Spiralbander  ange- 
wandt  habe,  wurden  getotet.  Es  atrophiert  nun  die  Aortenwand  unter  diesen 
Bandern  genau  so,  wie  unter  dem  Metallring,  und  es  durfte  von  Interesse 
sein,  die  genauen  Einzelheiten  des  Prozesses,  der  hier  und  da  zur  Bildung 
eines  bindegewebigen  Stranges  unter  dem  Bande  fiihrt,  auseinanderzusetzen. 
Exp.  1. — Die  Aorta  wurde  stark  durch  eine  kraftige  Seidenligatur  ge- 
quetscht  und  iiber  diese  Quetschfurche  wurde  ein  Spiralband  gelegt.  Die 
Untersuchung  der  Aorta  nach  2  Monaten  ergab,  dass  die  Intima  sich  im 
Bereiche  der  Quetschfurche  regeneriert  hatte,  die  anderen  Schichten  der 
Gefasse  aber  nicht. 

Exp.  2. — Bei  einem  anderen  Tiere  fiihrte  ich  einen  Seidenfaden  durch 
einen  Stichkanal  in  das  Lumen  der  Aorta  ein  und  an  einer  anderen  Stelle 
wieder  heraus.  Diese  Ligatur,  die  geknotet  wurde,  musste  auf  eine  kurze 
Strecke  frei  auf  der  Innenflache  des  Gefassrohres  verbleiben.  Die  Blutung, 
die  nach  diesem  Manover  erfolgte,  wurde  durch  Anwendung  des  Spiral- 
bandes  zum  Stehen  gebracht.  Die  Untersuchung  nach  2  Monaten  ergab,  dass 
der  Teil  des  Seidenfadens,  der  sich  wie  eine  Bogensehne  zwischen  einem 
kleinen  Arcus  der  Aortenwand  ausgespannt  hatte,  durch  negebildete  und 
normal  aussehende  Intima  hindurchschimmerte. 

Exp.  3. — Ein  feiner  Seidenfaden,  der  fest  genug  angezogen  war,  um  eine 
ansehnliche  Umschnurung  der  Aorta  herbeizufuhren,  wurde  mit  einem 
Spiralbande  bedeckt,  das  noch  weiter  das  Lumen  verengerte.  Nach  ungefahr 
6  Wochen  konnte  man  die  Ligatur  durch  normale  Intima  hindurchschim- 
mern  sehen.  Die  ausseren  Gef  assschichten  unter  dem  Bande  waren  verdiinnt, 
und  die  Ligatur  lag  lose  und  frei  zwischen  dem  Spiralbande  und  der  kom- 
primierten  Aortenwand. 

In  keinem  unserer  Versuche  haben  wir  die  geringste  Spur  von  Throm- 
bosenbildung  gesehen.  In  dieser  Hinsicht  steht  unsere  Erfahrung  in  auf- 
fallendem  Gegensatz  zu  derjenigen  anderer  Forscher,  welche  den  Totalver- 
schluss  mit  Ligatur  ausgefuhrt  haben. 

Beim  Menschen,  wie  gesagt,  hatte  ich  viermal  Gelegenheit,  den  Effekt 
des  partiellen  Aortenverschlusses  zu  beobachten.  In  keinem  Falle  hatten 
sich  beunruhigende  Symptome  gezeigt,  obgleich  bei  einem  Kranken  der 
Aortenverschluss  fast  so  vollkommen  gemacht  worden  war,  dass  der  Femoral- 
puls  sistierte.  Diese  Resultate  stehen  in  eklatantem  Gegensatz  zu  denjeni- 
gen,  die  nach  vollstandigem  Verschlusse  der  Aorta  erreicht  sind. 


426  DEE  PAETIELLE  YEESCHLUSS 

Nach  vollstandigem  Yerschlusse  der  Bauchaorta  bei  Hunden  kehrt  der 
Puis  der  Femoralis  gewohnlich  nicht  in  mehreren  Wochen  zuriick  und  in 
einigen  Fallen  konnten  wir  ihn  erst  nach  sieben  Monaten  palpatorisch  nach- 
weisen.  Die  Kollatcralbahnen  nehmen  ihren  Weg  durch  die  in  so  schoner 
Weise  von  Luigi  Porta  dargestellten  Yasa  vasorum  und  durch  die  Mam- 
maria  interna  und  die  epigastrischen  Gefasse,  auf  die  auch  besonders  durch 
Kast  mit  Xachdruck  hingewiesen  ist.  Wir  haben  \riederholt  die  grosse 
Zunahme  der  Gefiissversorgung  in  der  Bauchwand  nach  komplettem  Yer- 
schlusse der  Aorta  beobachten  konnen. 

Es  ist  erstaunlich.  dass  sogar  nach  langen  Zeitraumen  der  Blutdruck  ober- 
halb  und  unterhalb  des  Metallbandes  so  sehr  verschieden  ist. 

Beispiel.  Hund  Xr.  96.  Operation  am  22.  5.  1906.  Die  Lungen  wurden 
nach  Tracheotomie  in  gleichmassiger  Athmung  durch  Geblase  erhalten.  Ein 
Aluminiuniband  von  6  nini  Breite  und  einer  Dicke  von  Xr.  3  der  amerikan- 
ischen  Metallskala  wurden  run  die  Aorta  thoracica  genau  oberhalb  der 
starksten  Wolbung  des  Zwerchfelles  gelegt. 

19  Tage  nach  der  Operation  war  der  Hund  vollkommen  munter,  wenn- 
gleich  sehr  schwach  und  steif  auf  den  Hinterbeinen.  Am  20.  Tage  trat 
plotzlich  im  Befinden  des  Tieres  ein  TTechsel  ein.  Der  Hund  war  sehr 
matt,  athmete  ganz  oberilaclilich  und  die  Hinterbeine  waren  vollstandig 
gelahmt.  In  zrwei  oder  drei  Tagen  war  ein  geringer  Grad  von  Bewegung  der 
Hinterbeine  zuriickgekehrt. 

21.  12.  Sieben  Monate  nach  der  Operation  war  der  Hund  vollkommen 
munter.  wenngleich  noch  sehr  schwach  auf  den  Hinterbeinen.  Der  Femoral- 
puls  konnte  mit  Miihe  gefiihlt.,  aber  nicht  mit  geniigender  Sicherheit  ge- 
zahlt  werden.  Der  Thorax  wurde  unter  positivem  Druck  geoffnet  und  das 
Band  der  Aorta  thoracica  untersucht.  Es  war  deutlich  zu  sehen,  indem  es 
breit  durch  die  normal  aussehende  Pleura  hindurchschimmerte. 

Die  Blutdruckuntersuchungen,  die  von  Herrn  Dr.  Percy  Dawson,  Associ- 
ate Professor  fiir  Physiologie  an  der  Johns  Hopkins  Fniversitat  ausgefuhrt 
wurden,  fuhrten  zu  folgendem  Eesultate : 


HSchster 
Druck 

Mittlerer 
Druck 

Geringrster 
Druck 

Puls- 
Druck 

Femoralis 

116 

93 

8S 

» 

Carotis 

160 

113 

83 

77 

Bei  Kontrollhunden  wurden  durchschnittlich  folgende  Werte  gefunden: 


H5chster 
Druck 

Mittlerer 
Druck 

Gerinjrster 
Druck 

Puls- 
Druck 

Femoralis 

188 

120 

95 

93 

Carotis 

162 

122 

103 

49 

„  Auch  Druckkurven  wurden  beim  Hunde  Xr.   96  aufgezeichnet  und 
zeigten  ein  vollkommenes  Fehlen  dt-r  dikrotischen  Welle  beim  Femoralis- 


GEOSSEE  AETEEIEN  427 

puis,  wahrend  beim  Kontrolltier  die  dikrotische  Welle  in  der  Femoralis 
viel  markanter,  als  in  der  Carotis  ist,  so  dass  die  Hyperdikrotie  klarer  in  der 
ersteren,  als  in  der  letzteren  auf  zuzeichnen  ist." 

„  Betrachliche  Veranderungen  betreffs  der  Schnelligkeit  der  Pulswellen 
bieten  sich  bei  den  verschiedenen  Hunden  dar.  Nichtsdestoweniger  lasst 
sich  mit  Sicherheit  behaupten,  dass  die  Schnelligkeit  von  nur  556  cm  in  der 
Sekunde,  die  bei  diesem  Tiere  gefunden  wurde,  ihren  niedrigen  Wert  der 
Aorten-Umschniirung  verdankt." 

Es  erschien  uns  bemerkenswert,  dass  nach  einer  so  langen  Zeit  (annahernd 
nach  7  Monaten)  ein  soldier  Unterschied  im  Pulsdruck  oberhalb  und  unter- 
halb  der  partiellen  Umschniirung  vorhanden  war.  Das  Herz  pumpte  durch 
das  Band  einen  schmalen  Strom  hindurch  von  einer  Dicke,  wie  ihn  etwa 
die  Arteria  radialis  des  Menschen  zu  fiihren  pflegt.  Die  Pulsdruckdifferenz 
oberhalb  und  unterhalb  der  Bandes  betrug  49  mm,  wahrend  der  geringste 
Differenz-Druck  5  mm  Quecksilber  ergab. 

Es  wird  damit  verstandlich,  dass  der  partielle  Bandverschluss,  der  die 
Pulswelle  abschliesst,  aber  noch  einen  diinnen  Blutstrom  unter  dem  Bande 
hindurchlasst,  ausreicht,  in  einem  bestimmten  Prozentsatz  von  Fallen,  das 
Aneurysma  zu  heilen.  Gewohnlich  besteht  eine  erhebliche  Differenz  in  Form 
und  Dicke  der  Aorta  oberhalb  und  unterhalb  des  Bandes.  Die  Arterienwand 
iiber  dem  Bande  mag  mehr  als  zweimal  so  dick  sein  als  unter  demselben, 
und  ist  gewohnlich  dilatiert  (s.  Platte  XXIX,  4). 

Den  partiellen  Gefassverschluss  mit  dem  Metallring  habe  ich  beim  Men- 
schen bei  alien  grossen  Arterien  angewandt,  so :  einmal  bei  der  Aorta  thora- 
cica ;  dreimal  bei  der  Aorta  abdominalis ;  einmal  bei  der  Arteria  anonyma ; 
zweimal  bei  der  A.  subclavia ;  einmal  bei  der  A.  iliaca  communis ;  zweimal 
bei  der  A.  iliaca  externa;  zweimal  bei  der  A.  femoralis;  einmal  bei  der 
A.  poplitea,  und  verschiedene  Male  bei  der  A.  carotis. 

Ein  Band  wurde  mit  offensichtlichem  Nutzen  fur  das  Herz  bei  einer  stark 
dilatierten  Vena  iliofemoralis  oberhalb  einer  arteriovenosen  Kommunika- 
tion  angewandt.  Diese  hatte  ich  sorgfaltig  freigelegt,  in  der  Hoffnung,  die 
Kommunikatfonsoffnung  derselben  ohne  Obliteration  von  Vene  oder  Arterie 
verschliessen  zu  konnen.  Ein  anderes  Mai,  wahrend  ich  dabei  war,  ein 
Band  um  die  A.  ileofemoralis  unmittelbar  iiber  einem  Aneurysma  dieser 
Arterie  anzulegen,  wurde  der  Kranke  plotzlich  tief  cyanotisch  und  in 
wenigen  Minuten  horte  er  auf  zu  athmen.  In  der  Annahme,  dass  ein  ver- 
borgenes  Aneurysma  des  Aortenbogens  auf  die  Trachea  driicken  konnte, 
wurde  ein  Gummirohr  in  diese  eingefiihrt.  Dieses  verschaffte  dem  Kranken 
an  der  Trachealstenose  geniigende  Erleichterung,  so  dass  ich  in  die  Lage 
versetzt  war,  mein  Vorhaben  zu  Ende  zu  fiihren.  24  Stunden  spater  starb 
der  Kranke  plotzlich  in  Folge  von  Euptur  eines  kleinen  Aortenaneurysmas, 


428  DER  PAETIELLE  YERSCHLUSS 

welches  der  Grund  der  Trachealstenose  gewesen  war.  Dieser  Fall  eriimert 
mich  an  eiiie  fast  identische  Krankenbeobachtung,  die  mehrere  Jahre 
zuriickliegt.  Es  handelte  sich  um  einen  Xotfall.  Bei  dem  Kranken,  der 
bewusstlos  dem  Hospital  zugef  uhrt  wnrde,  versuchte  ich  3  Stunden  lang  das 
Aortenaneurysma  auszupraparieren.  Dieses  driickte  so  heftig  auf  die  Bifur- 
kation  der  Trachea,  dass  ein  steifer  Gummikatheter  durch  die  Tracheal- 
stenose hindurchgefiihrt,  in  solchem  Grade  plattgedriickt  wurde,  dass  der 
Patient  kein  anderes  Anastheticum,  als  seine  eigene  Kohlensaure,  bei  der 
Operation  notig  hatte.  Bei  der  Autopsie,  die  auf  dem  Operationstisch  ausge- 
fuhrt  wurde,  fand  sich,  dass  die  Ansschaltung  des  Aneurysma  sacciforme 
und  die  Yernahung  der  Kommunikationsoffnung  denkbar  gewesen  ware, 
hatte  die  Patientin  eine  oder  zwei  Stunden  langer  gelebt. 

Bei  meinen  operativen  Yersuchen  am  Aortenbogen  des  Menschen  und 
des  Hundes  habe  ich  den  Eindruck  gehabt,  dass  nach  chirurgischen  Ein- 
griffen  in  dieser  Gegend  der  Shock  ein  ungewohnlich  grosser  ist  und  es  wird 
von  Interesse  sein,  auszuprobieren,  ob  der  Shock  bei  weitgehendem  Gebrau- 
che  von  Lokalanasthesie  des  Mediastinums  sich  wesentlich  vermindern  lasst. 
Ich  mochte  hier  in  Parenthese  bemerken,  dass  ich  nicht  iiberzeugt  bin,  dass 
bei  gewohnlichen  Operationen  die  Yorteile  einer  kombinierten  ortlichen 
und  allgemeinen  Betaubung  bedeutend  grosser  sind  als  ihre  Xachteile. 
Oder  wenigstens  nicht  so  viel  grosser,  dass  die  haufige  bezw.  regelmassige 
Anwendung  der  kombinierten  Methode  indiciert  ware.  Die  lokale  Infiltra- 
tion mit  dem  Anastheticum  iibt  manchmal  einen  ungiinstigen  Einfluss  auf 
den  Heilungsprozess  aus,  und  die  Xachwirkungen  sogar  einer  geringen 
Xovocainmenge  sind  fiir  zartbesaitete  Patienten  sehr  unangenehm  und  pein- 
lich,  f  ernerhin  kommt  dazu,  dass  bei  Anwendung  der  kombinierten  Methode 
die  toxische  Wirkung  des  lokal  applicierten  Anastheticums  zu  derjenigen 
der  Allgemein-Xarkose  hinzutritt. 

Der  partielle  Bandverschluss  in  seiner  Anwendung  bei  Aneurysmen  der 
A.  carotis  communis  hat  ganz  besonders  interessante  Resultate  gezeitigt. 
In  vier  Fallen  habe  ich  ihn  in  der  erfolgreichsten  Weise  bei  diesem  Gefasse, 
zur  Beseitigung  der  Erscheinungen  von  Seiten  der  Augen  und  Ohren,  die 
in  evidenter  Weise  durch  die  Dilatation  des  Carotissackes  bedingt  waren, 
ausgefuhrt. 

Die  Gefahr  des  plotzlichen  kompletten  Yerschlusses  der  A.  carotis  ist  so 
gross,  dass  man  es  sich  doch  iiberlegen  sollte,  dieses  Gefass  allein  zur 
Beseitigung  der  Gerausche  und  des  Sausens  im  Ohr  sowie  der  Besehwerden 
im  Auge  und  der  geringfiigigen  Sehstorung  zu  unterbinden.  Matas,  Profes- 
sor an  der  Tulane  Universitiit  in  New  Orleans,  der  von  Anfang  an  meinem 
Unternehmen  seine  tatkriiftige  Forderung  und  Unterstiitzung  gewiihrt  hat, 
hatte  Gelegenheit,  im  Jahre  1907  oder  1908  ein  Metallband,  das  nach  seinen 


GROSSER  ARTERIEX  429 

eigenen  Angaben  gearbeitet  war.  an  der  A.  carotis  communis  in  Anwendung 
bringen  zu  konnen.  Er  konstatierte  nach  Entfernung  des  Bandes  eine  voll- 
standige  und  schnelle  Wiederherstellung  der  ernsten  Erscheinungen  von 
Seiten  des  Gehirns,  welche  die  Folge  des  Arterienverschlusses  gewesen 
waren.  Der  partielle  Yerschluss  der  Carotis  hat  unter  nieinen  Fallen  nnr 
zweinial  unbedeutende  und  schnell  voriibergehende  cerebrale  Symptome  her- 
vorgerufen.  In  keinem  einzigen  Falle  brauchte  ich  das  Metallband  wieder 
zu  entfernen. 

Die  Aufmerksamkeit  dieses  Kongresses  ist  zweimal  in  Anspruch  genoni- 
men  worden  anlasslich  der  Erorterung  des  temporaren  Yerschlusses  der 
Arterien,  und  zwar  von  Prof.  Jordan  1907  und  von  Dr.  Doberauer  1908. 
Keinem  der  beiden  Autoren  war  meine  fruhere  Arbeit  uber  diesen  Gegen- 
stand  bekannt. 

Der  partielle  Bandverschluss  hat  bestimmte  Yorteile  vor  der  temporaren 
Ligatur  von  Jordan  und  Doberauer: 

1.  Das  Band  braucht  nicht  wieder  entfernt  zu  werden. 

2.  Will  man  das  Band  wieder  entfernen,  so  sollte  man  es  an  seinem  Platze 
einige  Monate  liegen  lassen,  bis  Kollateralbahnen  entstanden  sind. 

Beilaufig  gesagt,  zu  dem  Yorschlage  des  Herm  Prof.  Jordan,  eine  tem- 
porare  Ligatur  bei  einer  verletzten  Arterie  proximal  von  der  Wundnaht 
anzulegen,  mochte  ich  bemerken,  dass  ich  wiederholt  bei  Tieren  die  in  die 
Aorta  gesetzten  Wunden  dadurch  geschlossen  habe,  dass  ich  ganz  einfach 
ein  nicht  komprimierendes  Metallband  rings  iiber  die  Wunden  herumlegte. 
Dieses  Yerfahren  diirfte  sich  fiir  den  Yerschluss  gewisser  pathologischer 
Perforationen  der  Aorta  eignen.  Ich  habe  einen  Eall  von  Berstung  eines 
Aneurysmas  der  Aorta  thoracica  gesehen,  welcher  mbglicherweise  nach 
diesem  Yerfahren  erfolgreich  hatte  behandelt  werden  konnen.  Durch  einen 
Spalt  von  der  Grosse  eines  Wurmloches  in  der  Wand  der  Aorta  thoracica 
hatte  das  Blut  seinen  Weg  zu  den  Aa.  iliacae  communes  genommen.  Der 
Kranke  lag  4  Tage  lang  in  schwerer  Agonie,  die  dem  plotzlichen  Einsetzen 
der  ersten  S}*mptome  gefolgt  war.  Es  ist  fiir  den  speziellen  Eall  von  Wich- 
tigkeit  hervorzuheben,  dass  der  Dickdarm  vom  Coecum  bis  zu  der  Flexura 
lienalis  so  enorm  gedehnt  war,  dass  eine  tangentiale  Colostomie  hatte  ge- 
macht  werden  miissen.  Kiirzlich,  als  Consiliarius  zu  einem  Knaben  gerufen, 
der  an  einer  enormen  Dehnung  der  Darme  im  Anschluss  an  eine  Xieren- 
exstirpation  litt,  glaubte  ich,  in  Erinnerung  an  diesen  soeben  citierten  Fall, 
an  die  Moglichkeit  einer  inneren  Blutung.  Die  Autopsie  deckte  ein  ausge- 
dehntes  extraperitoneales  Hamatom  auf.  Ich  erwahne  diese  Falle  absicht- 
lich,  in  der  Hoffnung,  dass  vielleicht  das  eine  oder  andere  Mitglied  dieser 
Gesellschaft  in  der  Lage  ist,  mir  eine  Erklarung  fiir  diese  Form  des  Ileus 
geben  zu  konnen. 


430  DER  PARTIELLE  YERSCHLUSS 

Yon  den  verschiedenen  interessanten  Fallen  des  partiellen  Yerschlusses 
einer  Arterie  mittels  der  Metallbandrolle,  die  wir  gehabt  haben,  berichte 
ich  den  folgenden  als  Beispiel. 

EXSTLRPATIOX    EIXES    ILIOFEMOBALEX    AXEUETSilAS    DEEI    "WOCHEX    XACH 

DEE    PRALIHIXAEEX,    TEILWEISEX    YeRSCHLIESSUXG    DEE 

A.   ILIACA  EXTEEXA 

"Walter  C,  40jahriger  Xeger,  wurde  am  10.  4.  1913  ins  Johns  Hopkins 
Hospital  aufgenommen.  Sieben  Monate  vor  seiner  Aufnahme  konstatierte 
der  Kranke  einen  dumpfen  Schmerz,  wenn  er  sich  biickte  und  fand  eine 
kleine  pulsierende  Beule  in  der  linken  Leistenbeuge,  welche  an  Grosse  stetig 
zugenommen  hatte.  Yor  5  Monaten  begann  das  Bein  anzuschwellen. 

Status:  Grosser,  muskuloser,  kraftiger  Xeger.  "Wassermann  schwach 
positiv.  Thorax :  ohne  Bef und,  mit  Ausnahme  eines  systolischen  Gerausches 
im  unteren  Teile  der  linken  Unterskapulargegend.  Obernachliche  Blutge- 
fasse  sklerotisch.   Blutdruck  130. 

Abdomen  aufgetrieben,  die  Hautvenen  iiber  der  linken  Seite  des  Leibes 
geschlangelt,  und  es  besteht  ein  Oedem  der  Haut,  das  bis  zur  zwolften  Rippe 
verlauft.  Ueber  der  Aorta,  die  ungewohnlich  breit  erscheint,  hort  man  ein 
deutliches  Gerausch.  Das  linke  Bein  ist  enorm  angeschwollen  von  der 
Leistengegend  bis  zur  Zehe,  und  so  derb  infiltriert,  dass  ein  starker  Druck 
kaum  die  Andeutung  einer  Delle  hinterlasst.  Der  ganze  Schenkel  zittert  mit 
jeder  Pulsation,  und  die  Haut  der  gesammten  Extremitat  ist  livid-schwarz 
verfarbt.  In  der  Gegend  der  Schenkelbeuge  befindet  sich  eine  machtige 
pulsierende  Geschwulst,  die  sich  von  der  Xahe  der  Schambein-Symphyse  bis 
zur  Spina  iliaca  anterior  superior  ossis  ilei  erstreckt  und  die  von  einer 
Linie,  die  durch  die  beiden  vorderen  Spinae  gezogen  ist,  nach  abwarts  bis 
10  cm  unter  das  Poupartsche  Band  reicht.  Die  genaue  Begrenzung  des 
Aneurysmas  konnte  nicht  ausgefiihrt  verden  wegen  der  grossen  Schwellung 
der  "Weichteile  rings  um  dasselbe;  die  Angaben  betreffs  der  Grosse  sind 
daher  nur  schatzungsweise  gegeben.  Ueber  der  Geschwulst  fiihlt  die  auf- 
gelegte  Hand  ein  Sch\virren,  und  ein  Gerausch  kann  man  von  der  abdomi- 
nalen  Aorta  an,  nach  abwarts  bis  zu  einem  Punkte  15  cm  unter  dem 
Poupart'schen  Bande  auskultatorisch  nachweisen. 

Maasse  der  beiden  Extremitaten 

Rechts  Links 

1.  In  der  Linie,  die  durch  die  Glutaalfalte  geht  48.5  cm  63     cm. 

2.  Ueber  dem  Knie  quer  iiber  der  Patella    33.5    "  45       " 

3.  Ueber  der  Wade,  15  cm  unter  dem  Kniegelenkspalt  31.5    "  40.5    " 

4.  Ueber  dem  Knochel,  2  cm  oberhalb  des  Malleolus  int 20       "  26.5    " 

In  der  Annahme,  dass  die  Gefahr  der  Gangran  in  diesem  Falle  unge- 
wohnlich gross  sein  wiirde,  entweder  bei  der  Ligatur  der  A.  iliaca  externa, 
bei  der  Exstirpation  des  Aneurysmasackes,  bei  der  von  Matas  angegebenen 
Endoaneurysmorrhaphie,  als  auch  iiberhaupt  bei  jeder  Methode,  welche  das 


GKOSSEK  AETEEIEN  431 

Aneurysma  sofort  zur  Heilung  bringen  will,  beschloss  ich  die  praliminare 
partielle  Verschliessung  der  A.  iliaca  externa  auszufuhren. 

21.  5.  1913.  I.  Operation.  Partielle  Verschliessung  der  linken  A.  iliaca 
externa  mit  Aluminiumband.  Die  Arterie  wurde  leicht  gefunden.  Sie  war 
abnorm  gross,  lag  sehr  tief  und  verlief  von  hinten  nach  vorn,  anstatt  von 
oben  nach  unten.  Das  Gefass  wurde  mit  zwei  langen  stumpfen  Dissektoren 
freigemacht,  aus  seinem  Bett  herausgehoben  mit  zwei  Haltefaden,  zwischen 
denen  das  Aluminiumband  um  dasselbe  geringelt  wurde.  Mit  Daumen  und 
Zeigefinger  wurde  das  Band  noch  fester  gerollt,  bis  ein  Schwirren  in  der 
Arterie  unter  demselben  deutlich  gefuhlt  werden  konnte.  Das  Band  wurde 
weiter  gerollt,  so  fest,  bis  auch  das  Schwirren  in  der  Arterie  und  die  Pulsa- 
tion im  Aneurysma  verschwunden  war.  Ein  ganz  schwacher,  kaum  f  uhlbarer 
Puis  konnte  noch  gerade  in  der  A.  iliaca  externa  zwischen  Band  und 
Aneurysma  palpatorisch  nachgewiesen  werden.  Auf  diese  Weise  war  das 
Gefass,  genau  dem  gewunschten  Grade  entsprechend,  verlegt  worden.  Der 
Fuss  wurde  sofort  ganz  kalt. 

Nach  Verschluss  der  Wunde  konnte  ein  schwaches  Gerausch,  jetzt  be- 
schrankt  auf  einen  Kaum  nicht  uber  4  cm  im  Quadrat,  direkt  unter  dem 
Poupartschen  Bande  gehort  werden.  Doch  war  dort  keine  sichere  Pulsation 
im  Aneurysma  vorhanden. 

22.  5.  24  Stunden  nach  Operation.  Circulation  im  Fuss  gebessert.  Patient 
kann  die  Zehen  und  das  Fussgelenk  frei  bewegen.  Er  hat  einige  Schmerzen 
im  Bein  gehabt.  Wahrend  der  Nacht  waren  die  Zehen  taub  und  gegen 
Beruhrung  unempfindlich.  Hatten  wir  die  Arterie  vollkommen  verschlossen, 
so  ware  wahrscheinlich  Gangran  eingetreten. 

23.  5.  Die  Schwellung  des  Gliedes  ist  vermindert.  Das  Schwirren  er- 
streckt  sich  hoher  oberhalb  des  Aneurysmas  und  entlang  dem  Verlaufe  der 
A.  iliaca  externa,  als  vor  der  Operation.  Hochstwahrscheinlich  ist  das  Band 
die  Ursache  dieser  Erscheinung. 

Ich  mochte  an  dieser  Stelle  bemerken,  dass  das  erwahnte  Schwirren  bei 
unseren  Tierversuchen,  wie  bei  den  operierten  Kranken  ein  wichtiger  Mass- 
stab  gewesen  ist,  da  es  ziemlich  genau  den  Grad  der  erreichten  Umschnurung 
anzuzeigen  pflegte.  In  den  Protokollen  unserer  Versuchstiere  zum  Beispiel 
lesen  wir  „  Die  Arterie  ist  bis  zu  dem  Eintritt  des  Schwirrens  verlegt 
worden  ",  oder  „  Das  Einsetzen  des  Schwirrens  erfolgte,  aber  der  Puis  ist 
noch  wahrnehmbar  ",  oder  „  Schwirren  und  Puis  sind  verschwunden,  aber 
das  Gefasslumen  ist  nicht  vollkommen  verschlossen  ". 

25.  5.  Patient  hat  keine  Schmerzen  mehr.  Sensibilitat  und  Temperatur- 
sinn  des  Gliedes  sind  normal.  Ein  voriibergehend  stark  erweiterter  Nebenast 
der  Vena  saphena  magna  ist  noch  weiter  sichtbar.  Es  scheint  das  Aneurysma 
zu  pulsieren. 

6.  6.  Die  Schwellung  des  ganzen  Gliedes  hat  seit  der  Operation  stetig 
abgenommen.  Es  besteht  eine  ganz  geringe,  aber  sichere  Pulsation  im 
Aneurysma. 

7.  6.  II.  Operation.  Entfernung  des  Aneurysmas.  Nach  Desinfektion 
der  Haut  mit  Alkohol  und  Jodtinktur,  wurde  das  Operationsfeld  ein- 
schliesslich  von  Scrotum,  Penis,  Abdomen,  Glutaalgegend,  Vorderflache  und 
Seiten  des  Gliedes  mit  einer  Schicht  von  feiner  Leinewand,  die  in  Celloidin 


432  DER  PAETIELLE  VERSCHLUSS 

getrankt  war,  bedeckt.  Ein  langer  senkrechter  Schnitt  wurde  durch  das 
trockene  Celloidin  und  die  Leinewand  iiber  der  Konvexitat  des  Aneurysmas 
an  der  hochsten  Stelle  gelegt.  Ehe  ich  mich  daran  machte  die  Iliaca  com- 
munis temporar  zu  verschliessen,  versuchte  ich  den  Sack  des  Aneurysmas 
moglichst  weit  auszuschalen.  Ich  tat  dies :  1.  in  der  Hoffnung,  die  Opera- 
tion nicht  unnotigerweise  durch  Auspraparieren  der  A.  iliaca  communis  zu 
komplicieren,  2.  weil  ich  den  Wunsch  hatte,  das  Verhalten  der  Kollateral- 
bahnen  der  A.  und  V.  femoralis  kennen  zu  lernen. 

Das  Gewebe  oberhalb  und  unterhalb  des  Aneurysmas  erschien  abnorm 
blutreich.  Zwei  grosse,  fiache  und  scheinbar  obliterierte  Venen  lagen  an  der 
Innenseite  des  Sackes.  Die  A.  epigastrica  und  die  A.  iliaca  externa  wurden 
durchtrennt  und  unterbunden.  Nachdem  die  Ausschalung  des  Sackes  am 
oberen  Pol  und  an  den  Seiten  blutlos  ausgef  iihrt  wurde,  schritt  ich  zur  tem- 
poraren  Kompression  der  A.  iliaca  communis.  Dieses  Gefass  wurde  frei- 
gelegt,  indem  der  Schnitt  nach  oben  iiber  dem  linken  M.  rectus  im  Verlaufe 
der  alten  Operationsnarbe  von  der  I.  Sitzung  gefiihrt  war.  Ein  dicker  Faden 
wurde  zweimal  rings  um  die  A.  iliaca  communis  gelegt  und  gedreht  bis  die 
Arterie  verschlossen  war.  Der  Grad  der  Drehung  wurde  mittelst  einer 
Klemme  erhalten. 

Ich  fand  das  Aneurysma  am  unteren  Pol  des  Sackes  in  einen  breiten 
Trichter  endigend,  von  dessen  innerer  und  hinterer  Wand  eine  grosse  Ar- 
terie, vermutlich  die  A.  profunda  f emoris,  abging.  Unmittelbar  unter  dieser 
trichterartigen  Erweiterung  wurde  die  A.  femoralis  zwischen  zwei  Ligaturen 
durchtrennt  und  der  Sack  von  unten  nach  oben  freigemacht.  Eine  ob- 
literierte Vene,  wahrscheinlich  die  Femoralis,  wurde  quer  durchschnitten 
und  mit  dem  Sack  entfernt.  Die  vergrosserte  A.  iliaca  externa  ging  ohne 
Veranderung  ihrer  Gestalt  unvermittelt  in  den  Aneurysmasack  iiber  und 
zwar  an  der  hinteren  Wand  des  oberen  Poles.  Das  Aneurysma  wurde  sodann 
der  Lange  nach  von  einem  Ende  zum  andern  gespalten  und  das  Blut  und 
die  Fibrinmassen  schnell  ausgeraumt.  Die  Wand  war  vollstandig  trocken, 
nicht  ein  einziger  Blutpunkt  war  sichtbar.  Es  zeigte  sich,  dass  der  Sack 
tief  in  das  Becken  hineinreichte.  Er  hatte  wahrscheinlich  die  A.  und  V. 
iliaca  interna  und  ihre  Aeste  komprimiert.  Die  weitere  Isolierung  war  sehr 
einfach  und  wurde  schnell  ausgef  iihrt;  nicht  ein  einziges  Gefass  brauchte 
unterbunden  zu  werden.  Nur  ganz  zum  Schluss  durchtrennte  der  letzte 
Messerschnitt  das  proximale  Ende  der  peripher  obliterierten  Vena  iliaca 
externa.    Die  ganze  Operation  wurde  vollstandig  unblutig  ausgefiihrt. 

Schluss  der  45  cm  langen  Operationswunde.  Einlegung  einer  kleinen 
Guttaperchacigarette.  Verband  mit  Silberfolie.  Nach  Beendigung  der 
Operation  war  der  linke  Fuss  und  das  linke  Bein  nach  oben  bis  zum  Knie 
deutlich  kalter,  als  auf  der  rechten  Seite.  Ein  Unterschied  in  der  Tempera- 
turempfindung  beider  Beine  wurde  bis  zum  5.  Tage  beobachtet. 

Als  der  Kranke  aus  der  Narkose  erwachte,  konnte  er  die  Zehen  und  das 
Fussgelenk  frei  bewegen.  Er  konstatierte  ein  taubes  Gefiihl  in  seinem  Fuss, 
konnte  aber  genau  Nadelstiche  an  jedem  Punkte  lokalisieren,  mit  Ausnahme 
am  inneren  Rande  des  grossen  Zehennagels,  und  konnte  vorziiglich  Heiss 
und  Kalt  unterscheiden. 

11.  6.  Erster  Verbandwechsel.  Wunde  per  primam  vollig  geheilt  mit 
Ausnahme  der  Drainageoffnung.    Patient  hat  sich  ausserordentlich  wohl 


GROSSER  ARTERIEN"  433 

gefiihlt  und  kein  Morphium  seit  der  Operation  erhalten.  Das  ganze,  stark 
geschwollene  Bern  ist  sehr  viel  diinner  geworden. 

16.  6.  (Neun  Tage  nach  der  Operation.)  Patient  ist  seit  einigen  Tagen 
herumgegangen.  Es  zeigt  sich,  dass  sein  Bein  vollkommen  wohlauf  ist  und 
schnell  an  Kraft  gewinnt.  Das  ganze  Glied  ist  weich  und  fast  normal.  Die 
anderweitige  Schwellung  ist  in  gleicher  Weise  verschwunden. 

November  1913.  Der  Kranke  schreibt  voll  Enthusiasmus  iiber  sein  Be- 
finden.  Er  berichtet,  dass  er  niemals  Anzeichen  von  Oedem  oder  Schwache 
oder  Gefiihlverlust  in  seinem  linken  Bein  bemerke.  Er  sei  imstande,  seine 
harte  Tagesarbeit  ohne  ungewohnliche  Ermiidung  auszufuhren. 

Ich  habe  diesen  Fall  deshalb  so  ausfiihrlich  wiedergegeben,  weil  er  in 
iiberzeugender  Weise  zu  beweisen  scheint,  dass  die  Behandlung  mit  dem 
Metallband  nicht  ohne  Vorteil  war. 

ZUSAMMENFASSUNG 

1.  Gewisse  Aneurysmen  konnen  durch  unvollstandigen  Verschluss  der 
Arterie  geheilt  werden. 

2.  Die  menschliche  Aorta  kann  ohne  Gefahr  bis  zu  einem  Volumen  ver- 
schlossen  werden,  welches  geniigt,  um  den  Femoralpuls  zu  unterdriicken. 

3.  Sollte  eine  Heilung  des  Aortenaneurysmas  auf  dem  Wege  des  primaren 
teilweisen  Verschlusses  nicht  zustande  kommen,  so  kann  man  die  Arterie  in 
der  Folgezeit  noch  weiter  komprimieren  oder  vielleicht  unterbinden,  je  nach- 
dem  das  Herz  durch  die  Erleichterung,  welche  ihm  der  gut  ausgebildete 
Kollateralkreislauf  gewahrt,  auf  den  vollstandigeren  resp.  totalen  Verschluss 
vorbereitet  ist. 

4.  An  der  normalen  Aorta  kann  man  einen  um  sie  gerollten  Metallstreifen 
mehrere  Monate,  moglicherweise  sogar  ein  Jahr  lang,  ohne  die  Gefahr  des 
Durchbruches  liegen  lassen,  so  lange  wenigstens  als  es  die  Sicherstellung 
der  Circulation  auf  dem  Wege  der  Anastomosen  erfordert.  An  der  erkrank- 
ten  Aorta,  insbesondere  wenn  die  Metallbandrolle  an  einer  trichterformigen 
Erweiterung  des  Gefasses,  wie  im  Falle  Prof.  Kocher's,  angelegt  wird,  kann 
die  Arterienwand  schon  in  der  kurzen  Zeit  von  sechs  Wochen  usurieren. 

5.  Der  Grad,  bis  zu  welchem  die  Aorta  ohne  Schaden  bei  Herzschwache 
komprimiert  werden  darf,  kann  natiirlich  nicht  bestimmt  f estgesetzt  werden. 

6.  Auf  Grund  meiner  Erfahrungen  glaube  ich,  dass  eine  Metallbandrolle 
ohne  die  Gefahr  einer  Hamorrhagie  dauernd  an  einer  Arterie  mit  Ausnahme 
der  Aorta  liegen  bleiben  kann.  Es  ist  wahrscheinlich,  dass  in  den  Fallen 
von  fast  vollstandigem  Arterienverschluss  (mit  Ausnahme  der  Aorta)  hau- 
fig,  wenn  nicht  sogar  gewohnlich,  die  Bildung  eines  fibrosen  Stranges  unter 
der  Metallbandrolle  eintritt.  Diese  TJmwandlung  der  Arterienwande  in 
einen  cylindrischen  Strang  habe  ich  4mal  bei  Versuchen  an  der  Aorta  des 

29 


434     DEE  PAETIELLE  VERSCHLUSS  GEOSSER  ARTERIEN 

Hundes  beobachtet.  In  jedem  dieser  Versuche  war  die  Aorta  fast  vollstandig 
durch  die  Metallbandrolle  verschlossen  worden. 

7.  Bei  alien  Arterien,  ausser  vielleicht  der  Aorta,  kann  die  Metallband- 
rolle so  fest  umgelegt  werden,  dass  der  Puis  (nicht  aber  der  Blutstrom) 
aufgehoben  wird,  falls  nicht  der  Zustand  des  Herzens  einen  so  festen  Ver- 
schluss  contraindiciert.  Die  Gefahr  der  Gangran  oder  Funktionsstorung  ist 
gering,  vorausgesetzt,  dass  nicht  die  ganze  Blutstromung  unterbrochen  wird. 

8.  In  einigen  Fallen  von  Aortenaneurysma  diirfte  es  moglichervreise 
ratsamer  sein  fiir  die  Umschniining  anstatt  des  Metalls  die  Fascia  lata, 
resp.  Aortenwand,  zn  verwenden ;  der  Grad  der  Kompression  mit  der  Fascia 
kann  nicht  so  genau  bestimmt,  anch  nicht  aufrecht  erhalten  werden  wie 
mit  dem  Metall.  Ueberdies  ist  fiir  die  Anwendung  von  Spiralen  aus  leben- 
dem  Ge-webe  sehr  viel,  dagegen  fiir  die  Anwendung  der  Metallbandrolle  nur 
sehr  wenig  Uebung  erforderlich. 

9.  Da  die  Arterienwand  vreder  von  dem  partiell  noch  total  verschliessen- 
den  Band  verletzt  wird,  so  kann  man  in  jedem  Augenblicke  das  Band  ent- 
fernen,  resp.  loser  oder  fester  anlegen. 


AS  TO  THE  CAUSE  OF  THE  DILATATION  OF  THE  SUBCLAVIAN 
ARTERY  IX  CERTAIN  CASES  OF  CERVICAL  RIB- 
EXPERIMENTAL  STUDY 1 

In  twenty-four  or  more  instances  a  circumscribed  dilatation  of  the  sub- 
clavian artery  has  been  observed  in  cases  of  cervical  rib.  The  dilatation  in 
these  cases  is  distal  to  the  site  of  pressure  made  by  the  rib. 

As  to  the  cause  of  these  aneurisms  there  has  been  considerable  conjec- 
ture, usually  prefaced  by  the  comment  that  their  occurrence  would  be  com- 
prehensible if  they  presented  on  the  proximal  instead  of  on  the  distal  side 
of  the  compression. 

"Weakening  of  the  wall  of  the  artery  from  erosion  or  trauma,  variable 
or  intermittent  pulse  pressure,  and  vasomotor  disturbances  in  nutrition 
are  the  suggestions  which  have  been  offered  to  explain  the  phenomenon. 

For  several  years  my  experiments  in  arterial  compression  have  had  more 
or  less  in  view  the  determination  of  the  cause  of  this  dilatation.  For  the 
past  year  they  have  been  continued  by  Dr.  Mont  Reid  and  myself  almost 
exclusively  with  the  object  of  shedding  light  on  this  problem.  In  1906  we 
(Dr.  Richardson,  Dr.  Dawson  and  myself)  made  the  observation5  that  after 
partial  occlusion  of  the  thoracic  aorta  the  maximum  pressure  may  be  per- 
manently lowered  as  much  as  46  mm.  Hg,  and  the  minimum  pressure 
actually  increased  distal  to  the  constricting  band  of  metal. 

The  dilatation  of  the  artery  observed  in  arterio-venous  fistula  might,  it 
seemed  to  me,  have  a  bearing  on  the  interpretation  of  the  aneurisms  in  cases 
of  cervical  rib.  Might  not  both  phenomena.  I  asked  myself,  be  due  to  degen- 
erative changes  in  the  arterial  wall  consequent  upon  lowered  pressure — 
in  the  case  of  the  cervical-rib-aneurisms,  upon  lowering  of  the  pulse  pressure. 

Now,  inasmuch  as  dilatation  of  the  subclavian  artery  has  relatively  so 
seldom  been  observed  with  cervical  rib   (perhaps  24  times  in  about  400 

1  By  Halsted,  W.  S,  and  Reid  M. 

Presented  before  the  Society  for  Experimental  Biology  and  Medicine  69th  Meet- 
ing, Cornell  University  Medical  College,  X.  Y,  October  20,  1915. 

(Abstr.)  Proc.  Soc.  Exper.  Biol.  &  Med.,  N.  Y,  1915,  xiii,  1-3.    (Reprinted.) 
"Dog  96.    Partial  Occlusion"  of  Thoracic  Aorta 
Operation,  22/5/1906.   Sacrificed  7  months  later 


Maximum 

Mean 

Minimum 

Pulse 

pressure 

pressure 

pressure 

pressure 

Femoral 

116 

93 

88 

2S 

Carotid 

160 

113 

S3 

77 
435 

436  SUBCLAVIAN  ARTERY  DILATION 

cases)  it  seemed  to  me  that  if  it  were  due  merely  to  the  lowered  pulse  pres- 
sure then  only  a  very  definite  absolute  or  relative  amount  of  reduction  of 
the  systolic  pressure  would  suffice  to  produce  it. 

In  June,  1914,  I  observed,  in  a  dog,  for  the  first  time  an  unquestionable 
dilatation  of  the  three  arteries  below  the  constricting  band  which  had  been 
placed  just  above  the  aortic  trifurcation.  The  constriction  exercised  by  the 
band  was  sufficient  to  greatly  lessen,  if  not,  indeed,  to  obliterate  the  palpable 
thrill  produced  by  the  constriction,  but  not  enough  to  shut  off  the  palpable 
pulse.  With  this  observation  as  fresh  incentive,  Dr.  Reid  and  I  have  con- 
tinued the  experiments  for  the  past  year  and  a  half  with  encouraging 
results :  in  only  one  additional  instance,  however,  was  there  a  very  striking 
dilatation.  In  this,  as  in  the  one  of  the  preceding  year,  the  occlusion  of 
the  aorta  by  the  band  was  almost  total. 

If  the  occlusion  must  be  so  nearly  complete  in  order  to  effect  a  pro- 
nounced dilatation  it  will  assist  to  explain  not  only  the  difficulty  we  have 
had  in  producing  it  in  dogs,  but  also  the  fact  that  it  has  been  observed 
relatively  so  seldom  in  the  human  subject  from  compression  of  the  sub- 
clavian artery  by  a  cervical  rib.  For  when  in  dogs  the  aortic  pulse  is 
occluded  beyond  the  stage  of  palpable  thrill  the  lumen  is  in  danger  of 
becoming  obliterated — as  by  the  formation  of  a  cylindrical  fibrous  cord 
beneath  the  band — and  thus  cancel  the  experiment;  and  in  the  cervical  rib 
cases  we  may  assume,  argumentatively,  that  the  subclavian  artery,  com- 
pressed to  the  stage  sufficient  to  produce  an  aneurism,  is  likely  to  become 
totally  occluded  in  the  presumably  considerable  time  required  for  the  mani- 
festation of  the  dilatation.  Thus,  in  dogs,  a  number  of  months  must  appar- 
ently elapse  after  the  application  of  the  band  before  a  dilatation  in  striking 
degree  can  occur.  In  the  two  cases,  observed  just  one  year  apart,  5  months 
and  20  days,  and  6  months  and  19  days,  respectively,  had  elapsed.  In  the 
second  of  these,  however,  a  dilatation  of  less  than  1  mm.  was  found  at  the 
expiration  of  2  months. 


AN  EXPERIMENTAL  STUDY  OF  CIRCUMSCRIBED  DILATION 
OF  AN  ARTERY  IMMEDIATELY  DISTAL  TO  A  PARTIALLY 
OCCLUDING  BAND,  AND  ITS  BEARING  ON  THE  DILATION 
OF  THE  SUBCLAVIAN  ARTERY  OBSERVED  IN  CERTAIN 
CASES  OF  CERVICAL  RIB x 

No  one,  since  Deitmar,2  has  attempted  to  collate  the  cases  of  dilation  of 
the  subclavian  artery  associated  with  cervical  rib.  Deitmar  cites  five  cases 
(Adams,  Coote,  Poland,  Baum,  and  von  Heinecke),  including  one 
(von  Heinecke's)  which  I  have  tabulated  as  doubtful.  Streissler's  review3 
is  perhaps  the  fullest  in  the  literature  on  the  subject  of  cervical  rib.  Although 
it  appeared  less  than  3  years  ago  no  addition  is  made  by  this  author  to 
Deitmar's  list. 

From  a  careful  study,  in  the  original,  of  the  reports  of  716  cases  of  cer- 
vical rib  I  find  that  aneurysm  or  dilation  of  the  subclavian  artery  was  noted 
in  27  or  more  of  them,  including  six  (Mayo,  Murphy,  Russel,  von  Heinecke, 
Galloway,  and  Seymour)  in  which  the  surgeon  believed  that  the  vessel  was 
abnormally  large,  and  two  (Karg  and  Halsted)  in  which  the  aneurysm 
appeared  promptly  after  removal  of  the  supernumerary  rib.  There  may  be 
numerous  other  instances  of  dilation  of  the  subclavian  associated  with  cer- 
vical rib — cases  in  which  the  amount  of  arterial  expansion  could  not  be  deter- 
mined in  the  lack  of  a  standard  of  comparison. 

The  Dilation  of  the  Subclavian  Abtery  Is  Distal  to  the  Line  of 
Constriction  Made  by  the  Rib  and  the  Scalenus  Anticus  Muscle 

As  to  the  cause  of  these  aneurisms  there  is  much  conjecture.  The  com- 
ment has  frequently  been  made  that  their  .occurrence  would  be  compre- 
hensible if  they  appeared  on  the  proximal  instead  of  the  peripheral  side  of 
the  compression.  No  one  has  remarked  that  dilation  central  to  the  site  of 
pressure  might  be  even  more  difficult  to  comprehend. 

1  It  is  possible  in  the  limits  of  the  permissible  space  to  present  the  results  of  the 
work  of  Dr.  Reid  and  myself  in  merest  outline.  A  full  account  will  probably  appear 
next  year  in  the  Reports  of  The  Johns  Hopkins  Hospital. 

Presented  before  the  American  Surgical  Association,  Washington,  D.  C,  May 
9-11,  1916. 

Received  for  publication  June  27,  1916. 

J.  Exper.  M.,  Bait,  1916,' xxiv,  271-286.    (Reprinted.) 

Aho:    Tr.  Am.  Surg.  Ass,  Phila,  1916,  xxxiv,  273-288. 

s  Deitmar,  J,  Inaug.  Diss,  Erlangen,  1907. 

3Streissler.  E,  Ergebn.  Chir.  u.  Orthop.,  1913,  v,  280. 

437 


438  CIECUMSCRIBED  DILATION  OF  ARTERY 

The  suggestions  which  have  been  offered  in  the  effort  to  explain  the 
phenomenon  are  as  follows :  ( 1 )  weakening  of  the  wall  of  the  artery  from 
erosion  or  other  trauma;  (2)  variable  or  intermittent  pulse  pressure; 
(3)  vasomotor  and  vasa  vasorum  disturbances. 

In  1906  Dr.  E.  H.  Richardson  and  I  made  the  observation  that  after 
partial  occlusion  of  the  thoracic  aorta  the  maximum  pressure  may  be  per- 
manently lowered  and  the  minimum  pressure  actually  increased  distal  to 
the  constricting  band  of  metal.  This  discovery  was  verified  by  Dr.  Dawson 
on  one  of  my  dogs  (No.  96). 

Dog  96.  Partial  Occlusion  of  the  Thoracic  Aorta 
Operation,  May  22,  1906.    Killed  7  months  later 

Maximum 


Mean 
pressure 

93 

Minimum 
pressure 

88 

Pulse 
pressure 

28 

113 

83 

77 

Femoral 116 

Carotid 160 

The  dilation  of  the  artery  observed  in  arterio-venous  fistula  might,  I 
thought,  have  a  bearing  on  the  interpretation  of  the  aneurisms  in  cases  of 
cervical  rib.  "  May  not  both  phenomena,"  I  asked  myself,  "  be  due  to 
degenerative  changes  in  the  arterial  wall  consequent  upon  lowered  pressure  ?  " 

Inasmuch  as  dilation  of  the  subclavian  artery  has,  relatively  to  the  num- 
ber of  cases  of  cervical  rib,  so  seldom  been  observed,  it  seemed  that  if  it  were 
due  merely  to  the  lowered  pulse  pressure,  then  only  a  very  definite  absolute 
or  relative  amount  of  reduction  of  the  systolic  pressure  would  suffice  to 
produce  it.  It  was  realized,  also,  that  even  if  the  amount  of  reduction  neces- 
sary to  accomplish  the  desired  result  could  be  determined  it  could  not  be 
constantly  maintained,  inasmuch  as  the  peripheral  resistance  becomes,  in 
great  measure,  rapidly  restored. 

For  a  number  of  years,  in  the  course  of  various  experiments  in  partial 
occlusion  of  the  arteries,  I  had  somewhat  in  view  the  chance  of  there  being 
produced  beyond  the  point  of  constriction  a  dilation  of  the  artery  analogous 
to  that  which  had  been  observed  in  cases  of  cervical  rib. 

The  Degree  of  Constriction  and  the  Period  of  Time  Required  for 
the  Production  of  the  Dilation 

Two  years  ago  when,  after  many  trials,  I  had  altogether  despaired  of 
having  the  hope  realized,  I  was  startled,  on  examining  the  abdomen  of  a 
dog  whose  aorta  had  been  constricted  for  5  months  and  20  days,  to  see  that 
each  of  the  branches  of  trifurcation  was  dilated  almost  to  the  size  of  the 
main  aortic  trunk.  About  to  leave  town  for  the  summer,  I  communicated 
the  finding  to  Dr.  Reid,  asking  him  promptly  to  repeat  the  experiment, 


DISTAL  TO  OCCLUDING  BAND 


439 


as  precisely  as  possible.  In  the  autumn  we  expectantly  laparotomized  three 
dogs  upon  which  Dr.  Eeid  had  operated  in  the  early  summer  and  were 
disappointed  to  find  that  no  change  had  taken  place  in  the  size  of  the  aorta 
or  its  three  terminal  branches.  Confident  that  there  could  have  been  no 
error  in  the  original  observation,  I  constricted  the  abdominal  aorta,  to  vari- 
ous degrees,  just  above  the  trifurcation  in  twenty  dogs  and,  at  intervals,  in 


Fig.  34.— Aorta  Before  the 
Band  was  Applied. 


Fig.  35.— Immediately    After 
Application  of  Band. 


Fig.  36.— Two    Months 
Thereafter. 


Fig.  34-37, 


Fig.  37.— Six  Months  and  19 
Days  Thereafter. 

Dog  7,  Series  I.    (The  Figures  are  Actual  Size.) 


the  course  of  the  winter,  explored  and  reexplored  the  abdominal  cavities, 
but  with  negative  result,  at  least  as  concerned  dilation. 

Finally,  on  opening  the  abdomen  of  our  last  dog  (No.  7)  we  found  the 
dilation  which  we  sought.  The  result  is  depicted  in  Figs.  34  to  37.  The 
occlusion  of  the  aorta  in  this  case  made  6  months  and  19  days  previously 
was  almost  complete,  just  as  it  had  been  in  the  one  successful  case  of  the 
foregoing  year — I  might  say,  of  all  the  foregone  years. 


440 


CIRCUMSCRIBED  DILATION  OF  ARTERY 


The  pressure  exercised  by  the  band  in  this  instance  had  been  sufficient 
to  lessen  greatly,  if  not  to  obliterate,  for  a  few  moments  at  least,  the  pal- 
pable thrill  produced  by  the  constriction,  but  not  enough  completely  to  shut 


4A> 


Fig.  3S.— Aorta  Before  the 
Band  Was  Applied. 


Fig.  39. — Immediately    After 
Application  of  the  Band. 


Fig.  40.— 97    Davs    Thereafter.  Fig.  41.— Nine  Months 

Thereafter. 
The  outer  of  the  two  con- 
centric circle*  indicates  the 
circumference  of  the  aorta  at 
the  site  of  the  band  before  its 
application:  the  inner  circles, 
the  precise  lumen  of  the  aorta 
under  the  band  when  the  dog 
was  killed. 

Figs.  3S-41.— Dog  3.  Series  II.    (The  Figures  are  Actual  Size.) 

off  the  palpable  pulse.  With  this  observation  as  a  fresh  incentive.  Dr.  Reid 
and  I  have  continued  the  experiments  during  the  current  academic  year 
with  encouraging  results. 


DISTAL  TO  OCCLUDING  BAND 


441 


If  the  occlusion  must  be  so  nearly  complete  in  order  to  effect  a  well  pro- 
nounced dilation,  it  will  explain  not  only  the  difficulty  we  have  had  in 
producing  it  in  dogs,  but  also  the  fact  that  it  has  been  observed  so  seldom 


Fig.  42.— Aorta  Before  ths 
Band  Was  Applied. 


Fig.  43.— Immediately    After 
Application  of  the  Band. 


L~» 


Fig.  44.— 160  Days  Thereafter. 
The  outer  of  the  two  con- 
centric circles  indicates  the 
circumference  of  the  aorta  at 
the  site  of  the  band  before  its 
application;  the  inner  circle, 
the  precise  lumen  of  the  aorta 
under  the  band  when  the  dog 
was  killed. 

Figs.  42-44.— Dog  15,  Series  II.    (The  Figures  are  Actual  Size.) 


in  the  human  subject  from  compression  of  the  subclavian  artery  by  a  cer- 
vical rib.  For  when  in  dogs  the  aortic  pulse  is  occluded  beyond  the  stage 
of  palpable  thrill  the  lumen  is  in  danger  of  becoming  obliterated,  as  by 
the  formation  of  a  cylindrical  fibrous  cord  beneath  the  band,  and  thus 


442  CIRCUMSCRIBED  DILATION  OF  AETERY 

cancelling  the  experiment;  and  in  the  cervical  rib  cases  we  may  assume 
argumentatively  that  the  subclavian  artery  compressed  to  the  stage  suffi- 
cient to  produce  an  aneurism  might  become  thickened  by  sclerotic  changes 
in  the  time  required  for  the  pronounced  manifestation  of  a  dilation.  Thus, 
a  moderate  dilation,  present  for  a  brief  period  prior  to  occlusion  of  the 
subclavian,  might  be  overlooked. 

In  dogs,  a  number  of  months  must  apparently  elapse  after  the  application 
of  the  band  before  a  dilation  in  striking  degree  can  occur.  In  the  two  cases 
(No.  7,  1913,  and  No.  7,  1914)  to  which  reference  has  been  made,  5  months 
and  20  days,  and  6  months  and  19  days,  respectively,  had  elapsed.  In  the 
second  of  these,  a  dilation  of  the  middle  branch  of  the  trifurcation  of 
2  mm.,  found  at  the  expiration  of  60  days,  had  increased  to  4  mm.  in  the 
course  of  the  following  4£  months  (Figs.  34  to  37).  Other  instances  of  like 
dilation  are  accurately  represented  in  Figs.  38  to  44.  The  amount  of  con- 
striction made  in  two  of  the  illustrated  cases  (Dogs  3  and  15,  Series  II) 
is  indicated  by  the  concentric  circles  of  Figs.  41  and  44. 

We  have  found  and  abstracted  reports  of  716  instances  of  cervical  rib, 
in  great  part  from  the  original. 

Clinical    cases    525 

Autopsies   91 

Museum    specimens    100 

Total    716 

Per  cent 

Cases  with  nerve  symptoms  alone 235        653 

Cases  with  nerve  and  vascular  symptoms 106        29.4 

Cases  with  vascular  symptoms  alone 19  5.3 

Total   360 

Five  hundred  twenty-five  were  clinical  cases;  91,  autopsy  findings;  and 
100,  museum  specimens.  Three  hundred  sixty  presented  symptoms  of 
pressure.  Of  these,  235  had  nerve  symptoms  alone :  106,  nerve  and  vas- 
cular; and  19,  only  vascular  symptoms.  Accordingly  we  have  reports  of 
125  cases  of  cervical  rib  in  which  vascular  symptoms  were  noted.  In  27  of 
these  (21.6  per  cent)  an  enlargement,  fusiform,  aneurismal,  or  cylindrical, 
was  observed,  and,  of  these,  in  the  majority,  the  disturbance  of  circulation 
was  severe,  6  cases  having  gangrene  of  fingers  on  the  affected  side  (Table  I). 

Of  the  thirty  dogs  with  aortic  constriction  upon  which  this  report  is  based 
there  was  pronounced  dilation,  for  a  short  distance,  of  the  vessels  below  the 
band  in  seven,  or  23.3  per  cent. 

It  is  interesting  to  note  the  correspondence  in  the  human  (21.6)  and 
canine  (23.3)  percentages.   We  must  not,  however,  overvalue  the  result  of 


DISTAL  TO  OCCLUDING  BAXD  443 

this  haphazard  sort  of  comparison,  for,  as  regards  the  human  cases  we  have 
depended  upon  the  impressions  of  surgeons,  who,  having  no  standards  of 
comparison,  having  made  no  measurements,  and  not  always  being  par- 
ticularly concerned  about  the  arterial  feature  of  the  case,  may  have  over- 
looked or  overestimated  variations  from  the  norm;  and,  as  regards  the 
thirty  dogs,  we  observed,  in  addition  to  the  seven  designated  as  major  dila- 
tions, ten  minor  ones.  The  seventeen  dilations  of  all  grades  represent  56.6 
per  cent  of  the  thirty  dogs.  The  percentage  is  even  greater  if  we  include  in 
our  calculation  only  the  dogs  of  the  past  year;  and,  for  another  year  of 
experimentation,  would  probably  be  greater  still. 

We  may.  I  think,  conclude  that  the  dilation  of  an  artery  produced  experi- 
mentally is  not  due  to  any  of  the  three  factors  proposed  as  causal  for  the 
aneurism  in  cases  of  cervical  rib. 

1.  Vasomotor  Paralysis. —  (a)  The  vasomotor  nerves  and  the  vasa  vasorum 
are  destroyed  by  the  moderately  constricting  and  totally  occluding  bands 
quite  as  surely  as  by  those  which,  occluding  almost  totally,  alone  have  pro- 
duced the  dilation.  (6)  Only  a  portion  of  the  circumference  of  the  sub- 
clavian artery  is  exposed  to  the  pressure  of  the  cervical  rib  and  the  scalenus 
anticus  muscle,  and  hence  only  a  fraction  of  the  vasomotor  nerves  or  vasa 
vasorum  could  be  pressed  upon. 

2.  Trauma. —  (a)  Usually,  the  dilation  is  fusiform  and  (&)  distal  to  the 
rib.    (c)  Trauma  is  excluded  as  a  factor  in  the  experimental  dilations. 

3.  Inconstant  Blood  Pressure. —  (a)  Patients  suffering  from  the  pressure- 
pain  of  cervical  rib  rarely  make  wide  excursion-movements  of  the  arm. 
(6)  The  degree  of  occlusion  is  constant  in  the  experimentally  constricted 
vessel. 

When  an  arterial  trunk  is  ligated  it  becomes  occluded  to  the  first  proximal 
and  first  distal  branches  by  a  process  of  cell  proliferation  which  ultimately 
reduces  the  artery  to  a  fibrous  strand. 

Is  There  a  Fall  ra  Blood  Pressure  ix  the  Dead  Arterlil  Pocket 

Which  May  Anticipate  axd  Possibly  Be  a  Causative  Factor 

ix  the  Obliteratiox  of  This  Portiox  of  ax  Artery? 

From  observations  which  I  have  made  on  man  and  dogs  I  am  quite  sure 
that  there  may  be  a  remarkable  fall  in  blood  pressure  in  what  I  have  termed 
the  "  dead  arterial  pocket/'  while  there  is  still  little  if  any  sign  of  diminu- 
tion in  the  calibre  of  this  portion  of  the  vessel.  For  example,  the  right 
common  carotid  artery  was  ligated  by  the  writer  in  a  case  of  aneurism  of  the 
external  carotid.  About  3  months  later,  in  the  course  of  an  operation  for 
the  excision  of  the  uncured  aneurism,  the  internal  carotid,  dead-pocketed 
between  the  circle  of  Willis  and  the  carotid  ventricle,  was  freely  exposed 
for  a  considerable  distance.   It  had  lost  its  cylindrical  form,  being  flat  and 


444  CIRCUMSCRIBED  DILATION  OF  ARTERY 

tape-like,  and,  although  evidently  possessing  a  considerable  lumen,  seemed 
to  be  empty.  When  pricked,  a  few  drops  of  blood  oozed  without  pulse  from 
the  little  cut.  The  artery  was  then  resected  between  two  ligatures.  Its  wall 
was  thickened  on  one  side  (Plate  XXXI,  1)  but  the  lumen  was  still  per- 
haps three  times  that  of  a  radial  artery.  Similar  observations  I  have  made 
twice  on  the  external  iliac  artery  of  the  dog  after  occlusion  of  this  vessel 
at  its  origin  from  the  aorta.  In  the  approximately  dead  pocket  between  the 
aorta  and  the  origin  of  the  circumflex  iliac  and  common  trunk  of  the  epigas- 
tric and  obturator  arteries  the  blood  pressure  must  have  been  almost  nil, 
because  from  a  little  slit  made  in  the  apparently  normal  arterial  wall  of 
the  relatively  empty  external  iliac  artery  the  blood  escaped  very  slowly  in 
a  tiny,  almost  pulseless  jet  about  1  cm.  high;  whereas,  from  the  femoral 
artery,  below  the  profunda,  the  blood  spurted  normally  from  a  similar 
knife-prick. 

Hence  in  an  artery  doomed  to  obliteration,  it  would  seem  that  the  blood 
pressure  may  be  lowered  before  the  occlusion  process  sets  in — the  lowered 
pressure  being,  perhaps,  the  immediate  factor  leading  to  the  obliteration. 

COXSIDEEATIOX    OF   THE    CAUSE    OF   THE    DILATION 

Can  these  observations  have  any  bearing  upon  the  explanation  of  the 
dilation  of  the  aorta  above  its  trifurcation,  of  its  triad  branches,  and  of 
the  carotid,  which  we  have  occasionally  observed  in  the  dog  distal  to  the 
partially  occluding  band  ? 

The  mechanical  engineer  knows  the  effect  upon  pressures  of  constricting 
a  rigid  tube  through  which  water  is  being  forced  at  a  given  pressure.  At 
the  site  of  the  constriction,  of  the  Venturi  meter,  the  pressure  is  diminished 
and  the  velocity  increased,  whereas  immediately  beyond  the  constriction 
both  the  normal  pressure  and  velocity  are  restored.  This  is  not,  however, 
true  of  the  constricted  arterial  tube.  Beyond  the  band  the  systolic  pressure 
may  be  lowered,  the  diastolic  pressure  increased,  and  the  pulse  pressure 
greatly  reduced  for  many  months  at  least. 

If  the  constriction  of  the  aorta  is  very  slight  the  effect  upon  the  blood 
pressures  is  usually  transient,  the  normal  pressures  being  reestablished 
within  a  few  hours  or,  indeed,  minutes.  But  if  the  artery  is  constricted  to 
the  point  of  almost  total  occlusion  the  pulse  pressure  below  the  band,  for  a 
time  almost  nil,  may  remain  lowered  and  the  diastolic  pressure,  relatively 
or  even  actually,  be  increased.  The  blood  stream  in  this  case,  passing  with 
greater  velocity  and  less  pressure  through  the  band  prevents  the  obliteration 
of  the  artery  to  the  nearest  branch,  the  pocket  being  not  a  dead  one  as  it  is 
in  the  case  of  total  obliteration.  The  blood  in  this  pocket  beyond  the  con- 
striction streams  in  whirlpools,  somewhat  as  in  the  vein  and,  also,  as  in  the 


DISTAL  TO  OCCLUDING  BAND  445 

artery  in  arteriovenous  fistula ;  the  thrill,  not  palpable  at  first,  later  may  be 
perceived  with  the  finger ;  and  the  bruit,  always  audible  with  the  stethoscope, 
becomes  louder  as  the  peripheral  arterial  resistance  increases. 

To  these  factors,  then — to  the  abnormal  play  of  the  blood  in  the  rela- 
tively, as  distinguished  from  the  absolutely  dead  pocket  and  to  the  absence 
of  normal  pulse  pressure,  essential  probably  to  the  maintenance  of  the 
integrity  of  the  arterial  wall — we  may  have  to  look  for  the  solution  of  our 
problem. 

It  is  not,  however,  denied  that  the  paralysis  of  the  vasomotor  nerves  and 
the  occlusion  of  the  vasa  vasorum  may  possibly  play  some  part  in  the  mani- 
festation. The  dilations  produced  experimentally,  like  those  observed  in 
cases  of  cervical  rib,  are,  as  I  have  said,  circumscribed.  We  had  conjectured 
that  the  delimitation  of  the  dilation  might  be  influenced  or  determined  by 
the  location  of  the  branches  of  the  affected  artery  beyond  the  constriction. 
In  one  instance,  however,  we  observed,  just  distal  to  a  partially  occluding 
band  applied  to  the  carotid  low  in  the  neck  of  a  dog,  a  circumscribed  dila- 
tion of  this  vessel,  the  branches  of  which  had  been  tied  and  divided.  In 
this  case  there  was  a  long  stretch  of  debranched  and  patulous  carotid  between 
its  dilated  portion  and  the  base  of  the  skull. 

Do  Intimal  Suefaces  Beought  Gently  in  Contact  Unite,  and  What 

Is  the  Peocess  by  Which  Obliteeation  of  an  Aeteey  Takes 

Place  aftee  Occlusion  by  Band  oe  Ligatuee? 

The  intimal  surfaces  of  arteries  brought  intact  in  apposition  whether 
by  ligature  or  by  band  never,  in  my  experience,  have  united.  This  state- 
ment will  be  received  sceptically,  for  it  is  at  variance  with  the  quite  uni- 
versally accepted  view,  that  uncrushed  intimal  surfaces  if  brought  gently  in 
contact  adhere  and  thus  occlude  the  artery.  In  the  ligation  of  the  larger 
arteries  we  have  been  taught  to  use  heavy  ligatures,  two  or  three  abreast, 
and  in  tightening  them  to  employ  only  enough  force  to  bring  the  intimal 
surfaces  in  contact,  a  force  not  sufficient  to  rupture  or  injure  the  intimal 
coat.  The  gross  and  microscopic  findings  in  the  sections  of  arteries  ligated 
in  this  manner  have  been  repeatedly  portrayed,  but  the  illustrations  sub- 
mitted as  proof  are  not  convincing, 
organization. 

It  is  my  opinion  that  the  pressure  necessary  to  bring  about  the  complete 
closure  of  the  aorta  causes  atrophy  of  the  arterial  wall  under  the  band,  and 
that  union  of  the  apposed  surfaces  thus  deprived  of  their  blood  supply  does 
not  occur.  To  accord  with  this  view,  how  is  to  be  explained  the  formation 
of  the  fibrous  cylinder  which  we  occasionally  find  encompassed  by  the  band, 
and  how  the  probable  error  of  other  investigators  who  believe  that  intimal 


446  CIECUMSCEIBED  DILATION  OF  AETEEY 

surfaces  brought  gently  in  contact  by  broad  ligatures  unite  primarily  and 
thus  interrupt  the  blood  stream  ? 

The  process  of  occlusion  is,  I  believe,  somewhat  as  follows:  The  death 
of  the  arterial  wall  having  been  brought  about  by  the  pressure  of  the  band, 
a  gradual  substitution  or  organization  of  the  necrotic  tissue  takes  place, 
the  new  blood  vessels  penetrating  it  from  both  ends.  The  absorption 
of  the  lifeless  wall  proceeds  coordinately  with  its  vascularization  or 
organization. 

If  the  band  has  been  rolled  so  tightly  as  to  occlude  the  lumen,  the  arterial 
wall  is  deeply  puckered  or  plicated.  If  after  a  month  or  two  the  aorta  is  cut 
open  at  this  point,  the  folds  of  the  arterial  wall  may  still  be  seen.  They 
will  not  be  adherent  to  each  other,  but  atrophied  possibly  to  the  thinness 
of  writing  or  tissue  paper.  The  attenuated  wall  can  still  be  completely 
unfolded.  In  some  cases  it  is  found  to  be  abnormally  thick  and  a  very  fine 
lumen  to  have  been  established  (Plate  XXXII,  1).  In  this  event  there  are 
no  folds,  the  thick  wall  consisting  altogether  of  new  tissue,  and  the  old  wall 
with  its  plication  having  been  absorbed.  Consequent  upon  the  atrophy  of 
the  arterial  wall  the  tension  under  the  band  is  eliminated,  capillaries  sprout 
into  the  necrotic  part,  which  thus  becomes  replaced  by  new  connective  tissue. 
A  tiny  blood  stream  may  make  its  way  under  the  band,  and  an  endothelial 
lining  for  the  new  wall  develop. 

More  often  we  find  in  the  completely  or  almost  completely  occluded  cases 
that  a  solid,  fibrous,  cylindrical  cord  completely  fills  the  space  within  the 
band  and  replaces  the  original  wall  of  the  artery. 

Although  we  are  unable  to  share  the  opinion  of  other  investigators  that 
the  uninjured  intimal  surfaces  of  large  arteries  adhere  to  each  other  when 
brought  in  contact,  the  advice  to  bring  broad  surfaces  in  apposition  by 
several  contiguous,  coarse  ligatures  is  good.  We  have  found  that  the  finer 
the  ligature  the  quicker  it  cuts  through  the  artery,  very  fine  silk  cutting 
through  in  a  day  or  two.  Narrow  tape,  constricting  the  artery  in  spiral  or 
cuff -like  form,  has  about  the  same  effect  upon  the  arterial  wall  as  the  metal 
band.  Under  three  or  four  coarse  ligatures,  drawn  tightly  enough  to  occlude 
the  lumen  but  not  so  tightly  as  to  injure  the  intima,  the  arterial  wall  would 
behave  presumably  as  it  does  under  the  tape  or  band,  and  occlusion  take 
place  in  the  described  manner.  I  should  think,  however,  that  it  would  be 
impossible  in  a  given  case  to  be  sure  that  each  one  of  three  ligatures,  for 
example,  had  occluded  the  artery  without  injury  to  the  intima.  Even  with 
the  metal  band,  which  can  be  rolled  with  great  precision  and  in  perfect, 
cylindrical  form,  it  is  not  possible  to  say  that  occlusion  has  no  more  than 
just  been  attained,  although  we  can  be  certain  that  the  intima  has  suffered 
no  trauma.   But  with  the  ligature  pressure  cannot  be  exerted  in  such  line 


DISTAL  TO  OCCLUDING  BAND  447 

and  exact  gradations ;  there  is  also  the  complication  of  the  knot  and  its  par- 
ticular pressure. 

The  surgeon's  conceptions  as  to  the  finer  processes  concerned  in  the 
occlusion  of  arteries  after  ligature  are  based  largely  upon  studies  undertaken 
before  the  days  of  perfected  asepsis,  in  the  days  when  thrombus  formation 
almost  invariably  complicated  the  picture. 

Summaey 

1.  A  partially  occluded  artery  may  dilate  distal  to  the  site  of  constriction. 

2.  The  dilation  is  circumscribed. 

3.  When  the  constriction  has  been  either  slight  in  amount  or  complete, 
dilation  has  not  been  observed. 

4.  The  dilation  was  greatest  when  the  lumen  of  the  artery  (the  aorta) 
was  reduced  to  one-third  or  perhaps  one-fourth  of  its  original  size  (Figs.  41 
and  44). 

5.  Dilation  or  aneurism  of  the  subclavian  artery  has  been  observed  twenty- 
seven  or  more  times  in  cases  of  cervical  rib. 

6.  The  dilation  of  the  subclavian  is  circumscribed,  is  distal  to  the  point 
of  constriction,  and  strikingly  resembles  the  dilation  which  we  have  pro- 
duced experimentally. 

7.  The  genesis  of  the  experimental  dilation  and  of  the  subclavian  dilation 
occurring  with  cervical  rib  is  probably  the  same. 

8.  When  the  lumen  of  the  aorta  is  considerably  constricted  the  systolic 
pressure  may  be  permanently  so  lowered  and  the  diastolic  pressure  so 
increased  that  the  pulse  pressure  is  greatly  diminished." 

9.  The  experimentally  produced  dilations  and  the  aneurisms  of  the  sub- 
clavian artery  in  cases  of  cervical  rib  are  probably  not  due  to  vasomotor 
paralysis,  trauma,  or  sudden  variations  in  blood  pressure. 

10.  The  abnormal,  whirlpool -like  play  of  the  blood  in  the  relatively  dead 
pocket  just  below  the  site  of  the  constriction,  and  the  lowered  pulse  pressure 
may  be  the  chief  factors  concerned  in  the  production  of  the  dilations. 

11.  Intimal  surfaces  brought,  however  gently,  in  contact  by  bands  or 
ligatures  do  not,  in  our  experience,  unite  by  first  intention,  for  the  force 
necessary  to  occlude  the  artery  is  sufficient  to  cause  necrosis  of  the  arterial 
wall. 

12.  Bands,  rolled  ever  so  tightly,  do  not  rupture  the  intima. 

13.  The  death  of  the  arterial  wall  having  been  brought  about  by  the 
pressure  of  the  band,  a  gradual  substitution  of  the  necrotic  tissue  takes 
place,  the  new  vessels  penetrating  it  from  both  ends.  It  is,  I  believe,  in  this 
manner  that  an  artery  becomes  occluded,  and  it  is  thus  that  a  fibrous  cord 
forms  within  the  constricting  band. 

1  See  Reid,  M.  R.,  J.  Exp.  Med.,  1916,  xxiv,  287. 


448 


CIRCUMSCRIBED  DILATION  OF  ARTERY 


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449 


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to  the  site  of  constriction. 

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eter between  artery  and  rib.  Resection 
of  part  of  the  rib. 

Aneurism  twice  needled   (before  discov- 
ery of  rib).    Finally  opened  and  rib 
removed.     Radial     pulse    "feebler"; 
became  fair  after  operation. 

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452  CIECUMSCEIBED  DILATION  OF  AETEEY 


EXPLANATION  OF  PLATE 

SECTION  OF  HUMAN  INTERNAL   CAROTID 

1.  Section  of  human  internal  carotid,  showing  the  process  of  obliteration  after 
ligation  of  the  common  carotid.  When  removed  at  a  subsequent  operation  this  artery 
was  found  pulseless  and  almost  empty  notwithstanding  the  size  of  its  lumen.    X  25. 

DOG  9,  SERIES  II.     (THE  FIGURE  IS  ACTUAL  SIZE) 

2.  The  band  was  rolled  so  tight  as  to  shut  off  the  palpable  thrill  but  not  the  pulse. 
When  killed  after  6  months  and  8  days  the  lumen  at  the  lower  edge  of  the  band  was 
12  mm.  in  diameter.  A  new  wall  had  been  formed  under  the  band,  thick  throughout, 
but  particularly  so  at  the  lower  and  upper  borders  of  the  band.  It  is  probable  that, 
in  this  case,  a  fibrous  cord  ultimately  would  have  formed. 


PLATE   XXXII 


PARTIAL  OCCLUSION  OF  THE  AORTA  WITH  THE 
METALLIC  BAND 

OBSERVATIONS  ON  BLOOD  PRESSURES  AND  CHANGES 
IN  THE  ARTERIAL  WALLS » 

In  all  except  one  of  the  aortic  experiments  of  Dr.  Halsted  and  myself 
the  constricting  aluminum  band  was  applied  to  the  abdominal  aorta  below 
its  inferior  mesenteric  branch.  At  the  time  of  our  final  observations  on 
these  animals  records  were  made  of  the  blood  pressures  in  the  femoral  and 
carotid  arteries.  Obviously,  in  order  to  draw  any  conclusions  as  to  the  effect 
of  the  band  on  the  blood  pressure  below  the  site  of  the  constriction,  the 
normal  relation  between  the  pressures  in  these  two  vessels  must  be  known. 

In  a  series  of  experiments  performed  by  Dr.  Dawson  on  dogs,  it  was 
learned  that  the  pulse  pressure  in  the  femoral  artery  is  normally  about 
twice  as  high  as  in  the  carotid.  The  femoral  systolic  pressure  is  higher  and 
the  diastolic  pressure  lower  than  the  corresponding  pressures  in  the  carotid 
artery  (Fig.  45). 

After  partial  occlusion  of  the  aorta  the  systolic  pressure  in  the  femoral 
is  markedly  lowered.  This  lowering  of  the  systolic  pressure  is  .due  mainly 
to  a  fall  in  the  pulse  pressure,  for  the  diastolic  pressure  remains  almost 
stationary,  or  may  be  actually  increased.  In  the  cases  of  most  marked 
dilation  the  femoral  pulse  pressure  was  only  about  one-half  the  carotid  pulse 
pressure,  while  the  femoral  diastolic  was  actually  greater  than  the  carotid 
diastolic  pressure  (Fig.  46). 

During  the  first  hour  after  the  application  of  a  moderately  tight  band 
the  femoral  pressures  undergo  marked  changes.  At  first  the  systolic  and 
diastolic  pressures  are  both  lowered.  In  a  few  minutes  the  diastolic  pressure 
may  become  even  greater  than  before  the  application  of  the  band,  while  the 
systolic  is  still  subnormal  (Fig.  47). 

After  complete  occlusion  of  the  aorta  the  normal  blood  pressure  relation 
between  the  femoral  and  carotid  arteries  may,  ultimately,  in  some  instances, 
be  reestablished. 

1  By  Mont  R.  Reid. 

This  communication  is  to  supplement  Dr.  Halsted's  paper,  "  Circumscribed  dila- 
tion of  an  artery  immediately  distal  to  a  partially  occluding  band,"  which  was 
published  in  J.  Exper.  M.,  Bait.,  1916,  xxiv,  271-286. 

Received  for  publication  June  27,  1916. 

J.  Exper.  M.,  Bait.,  1916,  xxiv,  287-290.    (Reprinted.) 

453 


454 


PAETIAL  OCCLUSION  OF  AORTA 


Gross  Effect  of  the  Band  on  the  Vessel  Wall. — In  some  cases  in  which 
the  band  has  been  loosely  applied,  only  slight  gross  alteration  in  the  wall  of 
the  vessel  under  the  band  is  found,  even  after  six  months.  On  removal  of 
the  band  the  plications  of  the  wall  can  be  unfolded,  and  the  intima  presents 
a  normal  looking,  smooth  surface  (Plate  XXXIII,  1). 

In  the  majority  of  cases  there  occurs  an  atrophy  or  necrosis  of  the  vessel 
wall  included  in  the  band.  In  some  cases  the  band  had  made  its  way 
through  the  atrophic  wall  into  the  lumen  of  the  vessel  (Plate  XXXIII,  2 


,  c.,S 


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-  -j  CD. 


F.S.  188.    F.D.   95.    Pulse  pressure  93. 
C.S.162.    CD.  103.    Pulse  pressure  59. 

Fia.  45 — The  normal  relation  be- 
tween the  systolic  and  diastolic  end 
pressures  in  the  femoral  and  carotid 
arteries  of  dogs. 


F.S.124. 
C.S.135. 


F.D.  86. 
C.D.72. 


Puke  pressure  38. 
Pulse   pressure  63. 


Fig.  46. — Systolic  and  diastolic  end 
pressures  in  Dog  7,  Series  I,  six  months 
and  10  days  after  the  band  was  ap- 
plied.   Good  dilation. 


and  3,  and  Plate  XXXIV,  1)  ;  in  these  a  new  wall  had  formed  outside  the 
band.  In  no  instance  was  there  leakage  of  blood.  On  splitting  open  the 
artery  for  examination  the  band  is  seen,  more  or  less  distinctly,  shimmering 
through  the  atrophic  arterial  wall.  This  wall  may  be  attenuated  to  a  veil- 
like thinness  or,  as  described,  may,  in  places,  have  entirely  disappeared, 
disclosing  portions  of  the  band.  The  upper  edge  of  the  band,  at  the  posterior 
surface  of  the  arterial  wall,  is  almost  invariably  the  first  part  to  be  exposed 
(Plate  XXXIII,  2  and  3). 

Histologic  Changes. — For  a  short  distance  below  the  site  of  the  band 
there  is  usually  a  definite  atrophy  of  the  elastic  and  muscular  tissues.   In 


BY  METALLIC  BANDS 


455 


Case  7,  Series  I  (Plate  XXXIV,  2,  c),  there  was  almost  a  complete  break 
in  the  elastic  tissue  below  the  edge  of  the  band.  The  connective  tissue 
throughout  the  wall  of  the  artery  seemed  to  be  little  affected  in  amount  in 
the  dilated  portion  of  the  vessel. 

At  the  site  of  the  band  the  new  wall  that  forms  over  it  is  composed 
mainly  of  fibrous  tissue  (Plate  XXXIV,  1,  and  Plate  XXXV).  Thus  far, 
none  of  our  cases  have  shown  regeneration  of  the  elastic  tissue  in  this  new 
wall. 


F.J3. 


KD. 


FS. 


XZ). 


A.  Without  band  175,  135. 

B.  Immediately  after  band  was  applied  131,  121. 

C.  5  minutes  later  135,  123. 

D.  25  minutes  later  155,  133. 

E.  35  minutes  later  167,  144. 

F.  35  +  minutes  later  167,  143. 

G.  Band  removed  189,  138. 

,  Fig.  47. — Systolic  and  diastolic  end  pressures  in  the 
femoral  artery  during  the  first  35  minutes  after  a  tight 
band  was  placed  around  the  aorta. 


In  the  fibrous  cord  (Plates  XXXVI,  XXXVII  and  XXXVIII)  which 
occasionally  forms  under  the  tightly  rolled  band  no  remains  of  the  vessel 
wall  have  been  found.  We  think  it  probable  that  the  original  arterial  wall 
undergoes  complete  atrophy  and  absorption  in  these  cases,  and  that  the 
cylindrical  cord  found  under  the  band  consists  of  new  tissue  which,  grow- 
ing in  from  above  and  below,  replaces  the  old.  This  cylindrical  fibrous  cord 
may  be  highly  vascularized  (Plate  XXXVIII).  We  have  found  no  evidence 
of  union  between  the  apposed  intimal  surfaces. 


456    PARTIAL  OCCLUSION  OF  AORTA  BY  METALLIC  BANDS 

EXPLANATION  OF  PLATES 

Plate  XXXIII 

1. — Dog  9,  Series  I.  The  band  was  rolled  to  the  early  stage  of  palpable  thrill.  The 
band  in  6  months  has  produced  only  slight  thinning  of  the  vessel  wall. 

2. — Dog  7,  Series  II.  Marked  constriction.  The  thrill  was  not  obliterated.  The 
band  had,  in  6  months,  cut  entirely  through  at  its  upper  edge,  posteriorly.  At  the 
lower  edge  of  the  band  there  is  still  a  remnant  of  the  atrophied  wall  (compare  Plate 
XXXIV,  1). 

3. — Dog  0,  Series  II.  The  band  was  tightly  rolled  but  not  totally  occluding.  At 
autopsy,  5i  months  later,  the  lumen  under  the  band  was  about  3  mm.  in  diameter. 
The  aortic  wall  was  so  thin  that  the  band  shimmered  through  it  everywhere,  and  had 
cut  through  at  several  places  along  the  upper  and  lower  edges.  A  new  arterial  wall, 
almost  complete,  had  formed  outside  the  band. 

Plate  XXXD7 

1. — Dog  7,  Series  II.  Longitudinal  section  through  the  arterial  walls,  old  and  new 
(compare  Plate  XXXIII,  2).  Weigert's  elastic  tissue  stain,  a  is  the  site  of  the  band; 
b,  elastic  tissue  of  the  aortic  wall  proximal  to  the  band;  c,  elastic  tissue  distal  to 
the  band;  e,  the  new  wall  which  had  formed  outside  the  band  where*  it  had  cut 
through,  posteriorly.  Between  a  and  the  lumen  of  the  vessel  the  original  wall  is 
greatly  thickened. 

2. — Dog  7,  Series  I.  The  band  was  tightened  until  the  thrill  disappeared ;  the  pulse 
was  not  obliterated.  Killed  after  6  months  and  19  days.  Longitudinal  section  through 
the  arterial  wall  at  the  site  of  the  band.  Weigert's  elastic  tissue  stain.  In  this  case 
there  was  marked  dilation  below  the  band,  a  is  the  site  of  the  band;  b,  the  aortic  wall 
proximal  to  the  band ;  c,  the  aortic  wall  distal  to  the  band,  showing  definite  atrophy 
and  a  break  in  the  elastic  tissue ;  e,  the  new  wall  that  had  formed  outside  the  band ; 
x  to  x,  the  segment  of  the  vessel  wall  that  had  been  included  by  the  band.  In  this 
segment  there  is  marked  atrophy  of  the  elastic  tissue,  particularly  at  the  edges  of  the 
band. 

Plate  XXXV 

Dog  17,  Series  I.  The  band  was  tightened  to  the  vanishing  side  of  the  thrill  stage. 
Longitudinal  section  through  the  arterial  wall  at  the  site  of  the  band.  Weigert's  elastic 
tissue  stain.  Under  the  band  the  elastic  tissue  is  rarified.  Below  the  band,  where 
there  was  a  moderate  amount  of  dilation,  atrophic  changes  are  noted,  a  is  the  slit 
occupied  by  the  band ;  6,  the  vessel  wall  proximal  to  the  band ;  c,  the  vessel  wall  distal 
to  the  band. 

Plate  XXXVI 

Dog  2,  Series  I.  The  band  was  tightened  until  the  pulse  had  just  disappeared. 
When  examined  after  7  months,  a  solid  fibrous,  cylindrical  cord  was  found  under  the 
band. 

Plate  XXXVII 

Dog  2,  Series  I.  Longitudinal  section  through  the  fibrous  cord  shown  in  Plate 
XXXVI.  Weigert's  elastic  tissue  stain,  a  is  the  site  of  the  band,  under  it  the  elastic 
tissue  has  vanished;  b,  the  vessel  wall  proximal  to  the  band;  c,  the  vessel  wall  distal 
to  the  band,  showing  definite  atrophy  of  the  elastic  tissue;  d  to  d',  the  fibrous  cord; 
e,  fibrous  tissue  that  formed  about  the  band.  There  is  almost  complete  disappearance 
of  the  elastic  tissue  at  the  site  of  the  band. 

Plate  XXXVIII 
Dog  2,  Series  I.  Transverse  section  of  the  fibrous  cord  through  d,  Plate  XXXVII. 
Hematoxylin  and  eosin. 


PLATE   XXXIII 


E.K« 


PLATE   XXXIV 


PLATE   XXXV 


PLATE   XXXVI 


PLATE   XXXVII 


PLATE   XXXVIII 


" 


"- 


Mi 


THE  IDEAL  OPERATION  FOR  ANEURISM;  A  CASE  OF 
LYMPHANGIOMATOUS  CYST ' 

Dr.  Bernheim  is  to  be  congratulated  greatly.  The  indications  for  the 
transplantation  seem  to  have  been  clear,  and  the  operation  was  a  complete 
success.  It  is  well  termed  the  "  ideal  operation,"  when  the  indications  for 
transplantation  are  so  definite  as  they  were  in  the  case  just  reported  by 
Dr.  Bernheim. 

We  are  indebted  to  Alexis  Carrel  for  making  such  an  operation  possible. 
Professor  Lexer,  the  distinguished  director  of  the  surgical  clinic  of  the 
University  of  Jena,  is  responsible  for  the  term,  and  he  was  probably  the  first 
to  transplant  a  blood  vessel  in  the  treatment  of  aneurism.  Many  surgical 
procedures  .have  been  called  "  ideal,"  and  for  their  time  have,  perhaps, 
deserved  the  appellation.  Most  of  them  were,  however,  short-lived.  Some 
surgeons,  myself 2  in  the  number,  have  advocated  excision  of  the  aneurism 
under  certain  conditions.  By  Bramann  and  by  Delbet  excision  was  termed 
the  "  ideal  operation."  Lexer  reported  his  first  case  at  a  meeting  of  the 
Deutsche  Gesellschaft  fiir  Chirurgie  eight  or  nine  years  ago.  The  operation 
was  for  an  aneurism  in  the  axilla,  the  result  of  an  attempt  by  some  surgeon 
to  reduce  an  old  dislocation  of  the  shoulder-joint.  The  operation  was  suc- 
cessful so  far  as  concerned  the  patency  of  the  vessels ;  but  the  patient  died 
in  a  few  days  of  delirium  tremens. 

Four  or  five  years  later  Lexer  reported  a  second  case,  also  successful. 
In  this  a  long  piece  of  the  saphenous  vein  was  transplanted  into  the  defect 
caused  by  the  excision  of  a  popliteal  aneurism.  Lexer  has  performed  his 
"  ideal  operation  "  in  a  third  case,  the  details  of  which  I  cannot  at  this 
moment  recall.  In  several  other  instances  in  the  human  subject  the  trans- 
plantation of  a  vein  to  replace  an  arterial  defect  has  been  undertaken, 
usually  with  unsuccessful  result.  The  surgeon  who  attempts  this  operation 
without  having  practised  it  on  animals  will  almost  surely  fail  to  accomplish 
it  successfully. 

Six  years  ago  I  invited  Dr.  Bernheim  to  transplant  for  me  a  long  piece 
(12  to  14  cm.)  of  the  saphenous  vein  into  an  arterial  defect  caused  by  the 
excision  of  a  sarcoma  of  the  popliteal  space.   In  this  case  the  popliteal  vein, 

1  Remarks  in  discussion  of  Dr.  Bertram  M.  Bernheim's  paper,  "  The  Ideal  Operation 
for  Aneurism  of  the  Extremity:  Report  of  a  case."  The  Johns  Hopkins  Hospital 
Medical  Society,  Baltimore,  October  18,  1915. 

Johns  Hopkins  Hosp.  Bull.,  Bait.,  1916,  xxvii,  94-96. 

2  Ligation  of  the  first  portion  of  the  left  subclavian  artery  and  excision  of  a  sub- 
clavioaxillary  aneurism.  Johns  Hopkins  Hosp.  Bull.,  1892,  iii,  p.  93. 

457 


458  ANEUEISM 

the  internal  popliteal  nerve  and  the  popliteal  artery,  from  Hunter's  canal 
almost  to  its  bifurcation  into  the  tibials,  had  been  excised.  The  vascular 
suture  at  the  lower  end  of  the  space  was  quite  difficult  on  account  of  the 
depth  of  the  wound  and  the  relatively  small  size  of  the  distal  stump  of  the 
artery.  For  a  time  the  circulation  through  the  transplant  was  perfect,  but 
the  interpolated  vein  became  thrombosed 3  before  the  wound  could  be  closed. 
Gangrene  did  not,  however,  ensue. 

I  might  mention  in  this  connection  that  an  end-to-end  suture  of  the  aorta 
has  been  successfully  accomplished.  In  excising  a  retroperitonaeal  tumor, 
Braun  tore  into  the  abdominal  aorta,  and  after  excising  about  2  cm.  of  this 
artery,  was  able  to  sew  the  widely  separated  ends  together. 

Professor  Kummel,  of  Hamburg,  told  me  of  a  recent  interesting  experi- 
ence of  his  own.  On  excising  a  tumor  he  made  a  hole  in  the  abdominal  aorta. 
This  he  closed  with  a  suture  of  coarse  silk  and,  if  I  remember  correctly, 
without  the  use  of  oil  or  vaseline.  A  second  uninterrupted  suture  of  fine 
silk  was  taken  to  reinforce  the  first. 

I  should  like  to  be  the  first  to  call  attention  to  a  possible  flaw  in  my 
argument  for  practising  the  partial  occlusion  of  an  artery  in  the  treatment 
of  certain  cases  of  aneurism.  As  some  of  you  perhaps  know,  I  advocate  the 
employment  of  a  band  which  can  readily  be  removed  and  which  does  not 
injure  the  wall  of  the  artery,  in  order  to  test  and  then  to  encourage  the 
anastomotic  circulation.  But  I  realize  that  it  may  be  possible,  even  with 
only  partial  occlusion,  to  interrupt  the  blood  flow  totally  and  too  quickly. 
Thus,  following  the  application  of  a  band  which  still  permits  a  small  stream 
to  flow  through  the  artery  to  the  aneurism,  the  latter  might  so  promptly 
become  solidified  by  the  clotting  of  its  contents  that  gangrene  should  be 
threatened.  It  is  obvious  that  in  such  a  case  removal  or  loosening  of  the 
band  might  not  restore  the  circulation  through  the  aneurism. 

My  own  experience  with  vascular  suture  in  the  human  subject  has  extended 
only  to  veins  and  to  the  lateral  suture  of  a  defect  of  the  femoral  artery  in 
Hunter's  canal. 

Of  particular  interest  to  me  is  the  case  of  a  patient  upon  whom,  with 
the  assistance  of  Dr.  Heuer,  I  operated  four  or  five  years  ago.  We  had 
about  completed  the  removal  of  a  very  large  lymphangiomatous  cyst  of  the 

*The  most  serious  objection  to  the  "ideal"  or  vein-grafting  operation  is  perhaps 
this:  that  in  case  of  failure  the  thrombosis  which  starts  in  the  graft  may  extend 
either  centrally  or  peripherally,  or  in  both  directions,  from  the  interpolated  vein 
into  the  artery  and  thus  involve  important  anastomotic  branches  which  would  not 
have  been  threatened  with  occlusion  if  the  artery  had  been  merely  ligated,  or  the  sac 
merely  excised  or  plicated.  The  transplanted  vein  is,  consequently,  a  menace,  for 
in  at  least  two-thirds  of  the  cases  in  which  the  "  ideal  operation  "  has  been  prac- 
tised, thrombosis  has  occurred  in  the  insert. 


LYMPHANGIOMATOUS  CYST  459 

abdomen.  There  remained  to  be  freed  only  its  connections  with  the  inferior 
vena  cava.  While  these  were  being  separated  with  extreme  caution,  blood 
gushed  from  this  vein.  There  proved  to  be  a  linear  defect  in  the  vena  cava 
so  long  that  six  artery  clamps  were  required  to  close  it.  A  lateral  suture  of 
the  vessel  with  oiled,  fine  silk  was  successfully  accomplished.  The  patient's 
convalescence  was  uneventful  and  she  is  at  the  present  time  in  excellent 
health.  The  defect  in  the  wall  of  the  vein  was  not  an  artefact.  It  repre- 
sented, I  believe,  an  imperfectly  closed  orifice  from  the  vein  to  a  lymph-bud 
or  lymphatic  vessel  from  which  the  cyst  had  had  its  origin.  I  expect  to 
report,  later,  this  case  and  an  analogous  one,  in  detail,  because  they  may 
serve  to  account  for  the  occasional  presence,  hitherto  unexplained,  of  blood 
in  certain  lymphangiomatous  cysts,  and  for  the  observations  that  cysts 
which  on  the  first  tapping  yielded  a  clear  fluid  have,  on  subsequent  tappings, 
been  found  to  contain  more  or  less  blood. 

Thus  Professor  Jordan  and  Professor  Voelcker  *  of  Heidelberg  refer  to  a 
case  of  cyst  of  the  neck,  reported  by  Weil,  which  had  its  origin,  he  believed, 
in  a  haemorrhage  from  the  vascular  wall  of  a  cystic  lymphangioma.  In 
support  of  Weil's  view,  the  authors  instance  the  observations,  repeatedly 
made,  that  cysts  from  which  at  the  first  puncture  only  a  clear  serous  fluid 
was  withdrawn  at  subsequent  aspirations  sometimes  yielded  blood.  And  one 
frequently  meets  with  the  statement  that  the  serous  content  of  lymphan- 
giomatous cysts  may  after  injury  become  bloody. 

As  a  possible  explanation  of  the  occasional  presence  of  blood  in  lymphan- 
giomatous cysts  I  would  suggest  that  a  primordial  communication  between 
the  vein  and  the  lymphatic  cyst  may  not  have  been  completely  closed.  The 
presence  of  blood,  at  subsequent  aspirations,  in  the  content  of  the  cysts, 
which  at  the  first  tapping  had  yielded  only  a  clear  serum,  might  be  due  to 
the  relief  of  tension  in  the  cyst  rather  than  to  an  injury  of  its  wall ;  for  the 
pressure  within  the  cyst  being  diminished  or  negatived,  there  might  be  a 
retrograde  flow  of  blood  from  the  original  venous  connection. 

In  one  of  my  cases,  a  supraclavicular  hygroma,  a  definite  relation  to  a 
large  vein  of  the  neck  was  demonstrated,  and  in  the  other,  as  I  have  related, 
there  was  an  intimate  connection  with  the  inferior  vena  cava  and  evidence 
of  an  opening  between  the  cyst  and  the  vein  which  may  have  become  closed 
more  or  less  completely  by  a  cribriform  fascia  of  some  sort.  It  is,  I  believe, 
very  improbable  that  the  thin  nonvascular  walls  of  either  of  these  lymphan- 
giomatous cysts  could  have  contributed  much,  if  indeed  any,  blood  to  their 
contents;  and  to  continuously  furnish  blood  enough  to  stain  the  fluid  for 
possible  frequent  subsequent  tappings  would,  it  seems  to  me,  have  been,  for 
such  walls,  impossible. 

4  Handbuch.  d.  prak.  Chir.,  Stuttgart,  1913,  4th  ed.,  p.  117. 


CYLINDRICAL  DILATION  OF  THE  COMMON  CAEOTID  ARTERY 
FOLLOWING  PARTIAL  OCCLUSION  OF  THE  INNOMINATE 
AND  LIGATION  OF  THE  SUBCLAVIAN  * 

The  following  unique  observation  confirms,  on  the  human  subject,  the 
discovery  made  on  dogs  that  a  partially  occluding  band  may  cause  a  distal 
dilation  of  the  artery,2  and  probably  sheds  light  on  the  pathogenesis  of  the 
aneurisms  of  the  subclavian  which  occur  in  cases  of  cervical  rib.  It  may, 
furthermore,  help  to  explain  the  dilatation  of  the  arterial  trunk,  which 
I  find  from  the  perusal  of  about  400  reports  has  quite  frequently  been  noted 
on  the  cardiac  side  of  arterio-venous  fistulae,8  and  which,  in  our  own  clinical 
and  experimental  cases,  has  occurred  invariably;  and  conceivably  it  may 
eventually  lead  to  the  discovery  of  a  law  or  laws  governing  the  preservation 
of  the  integrity  of  the  arterial  wall  and  thus  to  the  better  interpretation ' 
of  certain  pathological  phenomena  of  the  vascular  system. 

Mrs.  B.,  aged  fifty  years  (Surg.  No.  18357),  was  admitted  to  The  Johns 
Hopkins  Hospital  October  17,  1905,  suffering  from  a  large  aneurism  of  the 
right  subclavian  artery  (see  Plate  XXXIX,  1). 

November  17th,  First  Operation. — An  aluminum  band  was  applied  to  the 
innominate  artery  and  tightened  until  the  pulse  in  the  aneurism  was  almost 
completely  obliterated. 

January  12, 1906,  Second  Operation. — The  constriction  of  the  innominate 
artery  having,  apparently,  uninfluenced  the  aneurism  an  attempt  was  made 
to  excise  it.  Enucleation,  almost  accomplished,  was  not  completed  because 
the  sac  could  not  be  freed  from  the  subclavian  vein.  Hence,  the  subclavian 
artery  was  ligated  in  its  first  portion  close  to  its  origin  from  the  innominate 

1  Presented  before  the  American  Surgical  Association,  Cincinnati,  June  6-8,  1918. 
Tr.  Am.  Surg.  Ass.,  Phila.,  1918,  xxxvi,  501-518.    (Reprinted.) 
Also:   Surg.  Gyn.  &  Obst.,  Chicago,  1918,  xxvii,  547-554.    (Reprinted.) 
"Halsted  and  Reid:    An  Experimental  Study  of  Circumscribed  Dilation  of  an 
Artery  Immediately  Distal  to  a  Partially  Occluding  Band,  and  its  Bearing  on  the 
Dilation  of  the  Subclavian  Artery  Observed  in  Certain  Cases  of  Cervical  Rib.  Ibid.: 
Partial  Occlusion  of  the  Aorta  with  the  Metallic  Band.    Observations  on   Blood 
Pressures  and  Changes  in  the  Arterial  Walls.  Jour  Exp.  Med.,  1916,  xxiv,  271,  287. 
'  William  Hunter  was  first  to  describe  an  arterio-venous  aneurism.    He  noted  in 
his  first  and  second  Cases  what  so  many  surgeons  have  since  overlooked,  that  the 
artery  concerned  becomes  dilated  proximal  to  the  fistula.    Ibid.:    The  History  of 
an  Aneurism  of  the  Aorta,  with  Some  Remarks  on  Aneurisms  in  General.    Medical 
Observations  and  Inquiries,  1757,  i,  323.    Ibid.:    Further  Observations  upon  a  Par- 
ticular Species  of  Aneurism,  Medical  Observations  and  Inquiries,  1762,  ii,  390. 
460 


PLATE  XXXIX 


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DILATION  OF  COMMON  CAEOTID  ARTERY  461 

and  in  its  third  portion  on  the  confines  of  the  axillary  artery.  Both  of  the 
ligatures  were  tied  quite  close  to  the  aneurism,  which  had  been  so  thoroughly 
freed  in  the  course  of  the  dissection  as  to  make  their  application  easy. 
Pulsation  in  the  aneurism  was  completely  interrupted  for  a  few  minutes 
only.  Temporary  occlusion  of  the  right  common  carotid,  which  was  normal 
in  size,  seemed  to  be  without  influence  either  before  the  subclavian  was 
ligated  or  after  the  return  of  pulsation  in  the  sac  subsequent  to  the  ligations. 
A  light  plaster-of -Paris  dressing,  completely  concealing  the  feebly  pulsating 
aneurism,  was  applied. 

Ten  days  later  (January  22,  1906)  the  cast  was  removed  and  the  aneu- 
rism, to  my  surprise,  found  to  be  pulseless,  although  little  if  any  smaller. 

December  llfth. — Patient  returned  for  observation.  Dr.  Sowers  noted 
a  slight  systolic  bruit  distal  to  the  band  and  a  "  rumbling  systolic  bruit  "  on 
the  proximal  side  of  the  constriction. 

April  2,  1909. — There  is  a  circumscribed,  hard,  non-pulsating  nodule, 
about  the  size  of  a  Madeira  nut,  at  the  site  of  the  late  aneurism.  Pulse  in 
the  radial  artery  is  palpable.  No  disturbance  of  sensation  or  motion  is  com- 
plained of.  Patient  states  that  her  health  is  excellent  and  that  she  has  not 
been  annoyed  by  the  loss  of  the  clavicle  and  part  of  the  manubrium.  The 
right  common  carotid  is  dilated  to  about  twice  the  normal  size  throughout 
its  entire  length.  There  is,  however,  no  suggestion  of  a  circumscribed, 
aneurism-like  dilatation.  The  innominate  artery,  proximal  to  the  band,  is 
not  enlarged. 

March  31,  1911. — Note  by  Dr.  Heuer:  The  carotid  pulsates  strongly 
just  above  the  level  of  the  clavicle.  This  vessel  is  dilated,  having  a  diameter 
of  about  2.5  cm.  There  is  still  a  little  mass,  non-pulsating,  at  the  site  of  the 
former  aneurism.4  No  pulse  can  be  felt  in  the  right  radial  or  right  brachial. 
The  right  hand  is  a  little  colder  than  the  left,  but  there  is  no  swelling  of 
the  arm,  forearm  or  hand. 

March  16,  1917. — Note  by  Dr.  Sprunt:  There  is  marked  inequality  of 
the  radial  pulses,  the  right  being  the  smaller. 

February  15,  1918. — Note  by  Dr.  Reid:  Patient  has  come  from  her  home 
in  Washington  for  demonstration  at  Dr.  Halsted's  clinic.  She  states  that 
she  is  perfectly  well  and  has  no  abnormal  sensations.  Pressure  over  and 
just  above  the  band  compels  a  cough.  The  right  hand  seems  as  strong  as 
the  left  and  the  sensation  of  a  cold  right  hand,  of  which  she  was  formally 
conscious,  has  altogether  vanished.  The  last  trace  of  the  old  aneurismal  sac 
is  gone.  The  band  is  definitely  though  indistinctly  palpable.  There  is  a 
marked  dilation  of  the  right  common  carotid  from  the  band  to  the  bifurca- 
tion (see  Plate  XXXIX,  2  and  Fig.  48).  Below  the  band  one  can  trace  the 
innominate  artery  for  a  short  distance;  it  is  certainly  not  dilated  in  the 
proximal  portion. 

The  dilation  of  the  carotid  is  somewhat  fusiform  at  its  central  end.  The 
greatest  width  of  the  artery  (2.8  cm.)  is  about  1  cm.  above  the  upper  edge 
of  the  band.  From  this  point  (Fig.  48,  b)  the  diameter  diminishes  rather 
rapidly,  losing  1  cm.  in  an  equal  stretch  of  the  vessel,  which  then  maintains 

4  Thus  five  years  and  three  months  after  the  cure  of  the  aneurism  a  trace  of  the 
tumor  remained. 


462  DILATION  OF  COMMON  CAEOTID  AETEEY 

an  almost  cylindrical  but  slightly  tapering  form  to  the  bifurcation  (see 
Fig.  48).  The  innominate,  which  at  the  operation  was  considerably  con- 
stricted by  the  metal  tube,  is  now  smaller  below  than  above  it — smaller 
probably  than  normal.  A  distinct  bruit,  audible  along  the  whole  course  of 
the  right  carotid,  is  loudest  just  above  the  band.  It  is  not  heard  below  it, 
over  the  innominate.  Pressure  here  on  the  innominate  obliterates  the  pulse 
in  the  carotid.  The  blood  is  surely  coursing  through  the  aluminum  tube. 
The  heart  is  not  demonstrably  enlarged  nor  is  the  aorta.  The  right  radial 
pulse  is  feeble,  but  easily  countable.  Its  systolic  pressure  is  80  +  ;  the  dias- 
tolic pressure  cannot  be  accurately  determined.  In  the  left  arm  the  blood 
pressure  is  180/90. 


...  common  carotid 


'  innominate    artery 


Fig.  48. — Mrs.  B. ,  February  15,    1918.    Diagram,   actual   size,  made  from   Dr. 

Reid's  measurements. 

Thus  on  the  human  subject  we  have  now  a  striking  confirmation  of  the 
observations  which  Dr.  Eeid  and  I  have  made  upon  the  aorta  of  dogs.  Four 
or  five  times  in  the  past  twelve  and  a  half  years  this  most  obliging  of  patients 
has  journeyed  to  Baltimore  in  response  to  my  letters,  and  nine  years  ago 
I  made  a  note  of  the  remarkable  manifestation — a  cylindrical  dilation  of 
the  common  carotid  throughout  its  entire  length.  But  not  until  this  year 
did  the  explanation  of  the  phenomenon  occur  to  me,  although  for  many 
years  I  have  pondered  the  subject  of  the  dilations  distal  to  the  point  of 
constriction  in  cases  of  cervical  rib,  and  four  years  ago  observed  for  the  first 
time  a  dilation  of  the  aorta,  distal  to  a  partially  occluding  band,  in  the  dog 
(see  Figs.  34-37).  How  true  it  is  for  some  at  least  that  facts  may  almost 
strike  us  in  the  face  and  still  pass  unobserved. 


DILATION  OF  COMMON  CAEOTID  ARTERY  463 

In  the  analysis  of  525  clinical  cases  of  cervical  rib  I  found  106  in  which 
the  subclavian  artery  had  been  compressed,  and  that  in  27  of  these  aneurism 
or  dilatation  of  this  vessel  distal  to  the  site  of  constriction  had  been  noted. 
Interesting  illustrations  appear  in  the  papers  of  Keen "  and  Law '  (see 
Fig.  49  and  Plate  XL,  1). 

Dilatation  of  the  Heart  in  Cases  of  Arterio-Venous  Fistula 

A  particularly  interesting  result  of  our  clinical  and  experimental  studies 
of  arterio-venous  fistula  is  the  discovery  that  enlargement  of  the  heart  prob- 
ably occurs  after  a  time,  as  a  rule,  in  the  major  cases.  My  attention  was 
forcibly  called  to  this  complication  some  ten  years  ago  by  a  case  of  fistula 


Fig.  49; — 1,  cervical  rib;  2,  subclavian  artery  dilated  distal  to  the  site  of  con- 
striction; 3,  scalenus  anticus  muscle.  (Reproduced  by  the  courtesy  of  Dr.  W.  W. 
Keen  and  the  editor  of  the  American  Journal  of  the  Medical  Sciences.) 

of-  the  femoral  vessels  which  I  saw  in  consultation  with  Dr.  James  F. 
Mitchell,  of  Washington,  and  upon  which  together  we  operated  in  the  Provi- 
dence Hospital.  The  phenomenal  enlargement  of  the  heart  must,  I  thought, 
have  been  due  to  the  fistula,  and  have  been  secondary  to  the  enormous 
dilation  of  the  aorta  and  vena  cava.  Since  then  we  have  more  carefully  noted 
the  condition  of  the  heart  in  our  cases  of  arterio-venous  aneurism  and  have, 
I  believe,  quite  invariably  found  it  enlarged — strikingly  so  in  several  in- 
stances. If  the  assumption  is  correct  that  the  heart  dilates  in  consequence 
of  the  fistula  it  is  important  that  the  fact  should  be  brought  to  the  attention 

5  The  symptomatology,  diagnosis  and  surgical  treatment  of  cervical  ribs,  Am.  Jour. 
Med.  Sc,  Philadelphia,  1907,  cxxxiii,  173. 
•  The  surgical  aspect  of  cervical  ribs,  Journal-Lancet,  Minneapolis,  1914,  xxxiv,  330. 


464  DILATION  OF  COMMON  CAEOTID  AETEEY 

not  only  of  surgeons  but  also  of  pathologists  and  internists  who  apparently 
hare  altogether  overlooked  it.  Dr.  Mont  Keid  has  in  preparation  a  report 
upon  his  experimental  and  clinical  work  in  arterio-venous  fistula  in  which 
he  will  offer  convincing  experimental  proof  of  our  view  that  the  fistula  may 
in  its  consequences  profoundly  affect  the  heart  as  well  as  the  veins  and 
arteries :  and  Dr.  Curie  L.  Callander  is  makinsr  a  careful  studv  of  all  the 
reported  cases  of  arterio-venous  fistula  in  order  to  weigh  the  clinical  evidence 
bearing  on  this  subject  which  these  records  may  furnish. 

When  a  causative  relationship  between  arterio-venous  fistula  and  dilation 
hypertrophy  of  the  heart  shall  have  become  convincingly  established  we 
may  find  that  some  unexplained  dilations  of  the  heart  are  referable  to 
hitherto  undetected  changes  in  the  walls  and  lumen  of  the  blood  vessels. 
That  a  very  considerable  dilation  of  blood  vessels  may  be  overlooked  at 
autopsy  our  experiments  in  the  partial  occlusion  of  arteries  has  convinced 
dr.  I:  ia  impossible  to  estimate  the  amount  of  dilation  of  either  an  artery 
or  a  vein  in  its  collapsed  state.  Arteries  as  well  as  veins  which,  when 
empty,  give  no  indication  of  increase  in  calibre  may,  on  injection,  prove  to 
have  been  markedly  dilated.  All  surgeons  know  how  true  this  is  of  veins. 
A  vein  to  which,  when  full  of  blood,  von  Langenbeck  in  deference  would, 
as  he  said,  remove  his  hat,  might,  when  empty,  be  hardly  recognizable  in 
the  course  of  an  operation. 

There  may  be  more  or  less  circumscribed  aneurismal  expansions  in  the 
continuity  of  the  otherwise  cylindrically  dilated,  proximal  arterial  trunks. 
I  have  observed  this  in  two  or  three  of  my  patients.  One  such  expansion  is 
shown  proximal  to  the  fistula  in  the  postmortem  specimen  of  a  famous  case 
reported  by  Osier T  (see  Fig.  50  )and  another  in  Eisenbrev's  J  particularly 
interesting  illustration  (see  Plate  XL.  8).  I  am  quite  sure  that  in  Osier's 
case  there  was  a  much  greater  dilation  of  the  artery  above  the  aneurism  and 
between  the  aneurism  and  the  fistula  than  the  drawing  indicates,  for,  as  I 
have  said,  one  cannot  judge  of  the  size  of  the  lumen  from  the  appearance 
of  the  empty  vessel.  It  would  interest  Sir  William  to  compare  the  very 
similar  drawings  illustrative  of  the  two  cases,  his  own  and  Eisenbre; 
the  latter^  proves  that  the  fistula  may  be  a  considerable  distance  below  the 
point  at  which  the  artery  has  become  conspicuously  dilated  and  thus  offers 
strong  presumptive  evidence  that  the  reason  why  the  specimen  of  the  former 
lacks  the  evidence  of  the  fistula  is  because  it  was  too  greatly  curtailed  by  the 

T  Case  of  arterio-venous  aneurism  of  the  axillary  artery  and  vein  of  fourteen  years' 
duration.   Ann  Surg..  Philadelphia,  1S93.  xvii.  37.  Ibid.:   an  arterio-venous  aneurism 
.  of  the  axillary  vessels  of  thirty  years'  duration.    Lancet.   London.    1913,   ii.    124$. 
Makins.  G.  H.:   surgical  experiences  in  South  Africa.  2d  ed..  1913.  p.  US 

*  Arterio-venous  aneurism  of  the  superficial  femoral  vessels.  Jour.  Am.  Med.  Assn., 
Chicago.  1913.  lxi.  2155. 


DILATION  OF  COMMON  CAKOTID  AETERY 


465 


pathologist.  The  pathologist,  by  the  way,  should  not  be  too  harshly  cen- 
sured for  missing  the  key  to  the  situation,  for  if,  perchance,  he  had  been 
aware  that  the  artery  should  be  dilated  central  to  the  fistula  he  could  hardly 
by  any  possibility  have  known  that  it  might  retain  approximately  its  normal 
calibre  for  a  distance  so  far  from  the  arterio-venous  communication. 

Thanks  to  the  assistance  of  highly  competent  secretaries,  I  have  abstracts 
of  380  cases  of  arterio-venous  fistula.  These  have  been  studied  with  special 
reference  to  occasional  observations  on  the  dilation  of  the  artery.    In  52 


Fig.  50. — Dilation  of  the  external  and  common  iliac  arteries  and  veins  proximal 
to  a  fistula  of  the  superficial  femoral  vessels.  Reproduced  by  the  courtesy  of  Dr.  A. 
B.  Eisenbrey  and  of  the  editor  of  the  Journal  of  the  American  Medical  Association.) 

instances  proximal  dilation  of  the  arterial  trunk  has  been  noted.  In  11,  dila- 
tion was  mentioned,  but  whether  proximal  or  distal  or  both  is  not  specified. 
I  am  quite  sure  that  in  almost  every  instance  in  which  the  fistula  had 
existed  two  months  or  more  proximal  dilation  of  the  artery  would  have 
been  ascertainable  if  looked  for.  The  size  of  the  involved  artery  both  above 
and  below  the  fistula  should  always  be  compared  with  that  of  its  fellow. 
The  dilation,  as  a  rule,  extends  probably  to  the  heart,  which  also  in  my 
31 


466  DILATION  OF  COMMON  CAEOTID  ARTERY 

opinion  is  likely,  as  I  have  said,  to  be  dilated.  The  size  of  the  narrowed 
artery  below  the  fistula  may  be  difficult  to  determine  without  dissection. 
In  view  of  the  observations  of  Luigi  Porta,  Dr.  Reid  and  myself,  it  would 
be  well  also  to  bear  in  mind  the  possibility  of  a  dilation  of  any  great  artery 
distal  to  the  site  of  ligation,  and  the  probability  of  such  dilation  if  per- 
chance the  lumen  were  in  some  measure  to  be  reestablished.  As  the  dilation 
•distal  to  a  totally  occluding  ligature  has  been  observed  only  in  dogs  and  only 
in  the  aorta  and  its  triad  of  branches  further  experimentation  is  necessary 
for  the  determination  of  the  part  played  by  other  possible  factors,  for 
example,  by  the  anastomotic  circulation  and  by  the  proximity  of  the  nearest 
branches — by  the  length  of  the  dead  arterial  pocket,  in  other  words. 

In  a  previous  paper9  I  made  the  statement  that  dilation  had  not  been 
observed  below  a  totally  occluding  band.  Since  then,  however,  a  slight 
degree  of  dilation,  distal  to  the  completely  obturated  vessel,  has  taken  place 
in  three  instances.  A  dilation  of  this  ventricle-like  portion  of  the  aorta 
between  the  band  and  the  trifurcation  might  be  expected  even  in  case  of 
complete  occlusion,  for  the  anastomosis  is  very  free  in  this  situation  and 
the  dead  pocket  is  usually,  and  perhaps  always,  too  short  to  become  obliter- 
ated. Lumbar  branches  may  be  given  off  just  below,  as  they  are  just  above 
the  band. 

In  two  instances  I  have  made  the  following  observation  in  testing,  during 
the  life  of  the  animal,  for  the  patency  of  the  aorta  under  the  band.  Pressure 
with  the  finger  immediately  above  the  band  shut  off  the  pulse  in  what  we 
term  the  ventricle;  whereas,  pressure  with  the  back  of  the  scalpel  blade, 
made  as  close  to  the  band  as  possible,  did  not.  In  these  cases  there  was  a 
patent  lumbar  artery  so  close  to  the  proximal  edge  of  the  band  that  pressure 
by  the  finger  obliterated  it,  whereas  the  knife  blade  which  could  be  brought 
to  bear  on  the  aortic  wall  between  this  little  artery  and  the  upper  edge  of 
the  band  did  not  interrupt  the  flow  in  this  important  anastomotic  branch. 
The  contribution  of  this  little  artery  to  the  anastomotic  bloodstream  was 
sufficient  to  convert  an  inpalpable  into  a  palpable  pulse.  A  palpable  pulse 
in  the  ventricle  below  the  band  is  so  invariable,  whether  the  aorta  has  been 
completely  occluded  or  not,  that  the  patency  of  the  artery  under  the  band 
cannot  be  definitely  determined  during  the  life  of  the  animal  unless  tem- 
porary occlusion  of  it  between  the  band  and  the  nearest  lumbar  artery 
obliterates  or  decidedly  influences  the  pulse  in  the  ventricle.  If  pressure 
above  the  band  does  not  affect  the  pulse  just  below  it  we  may  conclude  that 
obturation  is  complete. 

Fortunately  it  occurred  to  me  a  few  days  ago  to  restudy,  with  reference 
to  the  possibility  of  finding  depicted  a  dilation  of  an  artery  below  a  liga- 

*  Halsted  and  Reid :    hoc.  cit. 


PLATE    XLI 


sr  i  \  >  v 


1.  —  The     aorta     of  2. — The  aorta  of  a  dog  fifteen  months  after  ligation, 

a    dog    eight    months  Note  the  distal  dilatation  and  the  anastomotic  circu- 

after    ligation.     Aorta  lation.    (Luigi  Porta,  loc.  cit.) 
dilated    distal   to    the 
site    of    the    ligation. 
(Luigi  Porta,  loc.  cit.) 


DILATION  OF  COMMON  CAROTID  ARTERY  467 

ture,  the  sketches  of  surgeons  -who  in  bygone  years  had  experimentally 
ligated  the  blood  vessels  of  animals.  I  was  delightfully  surprised  to  find,  in 
the  beautifully  illustrated  volume  of  Luigi  Porta,"  published  in  1845,  two 
drawings  which  portray  a  pronounced  dilatation  of  the  aorta  and  its  ven- 
tricle immediately  below  the  site  of  ligation  (see  Plate  XLI,  1  and  2).  The 
ligatures  in  the  two  dogs  had  been  applied  eight  and  fifteen  months  before 
the  death  of  the  animals.  There  is  a  great  bundle  of  dilated  vessels — the 
vasa  vasis — bridging  the  gap  between  the  retracted  ends  of  the  dilated  aorta 
(Plate  XLI,  2). 

Thus  three-quarters  of  a  century  ago  this  great,  perhaps  the  greatest, 
surgeon  of  Italy  furnished  irrefutable  proof  of  a  remarkable  phenomenon 
which  must  eventually  have  interest  for  the  physiologist,  the  pathologist  and 
the  surgeon.  Luigi  Porta  describes  the  drawing  but  makes  no  further  com- 
ment upon  the  dilation. 

Before  the  introduction  of  antiseptic  surgery  by  Lister,  thrombosis  quite 
invariably  followed  ligation  of  an  artery,  and  it  was  to  the  organization 
of  the  thrombus  that  the  surgeon  looked  for  the  prevention  of  secondary 
haemorrhage  and  for  the  preservation  of  the  life  of  the  patient.  If  thrombi 
formed  in  these  two  cases  of  Porta  they  must  have  been  eventually  ab- 
sorbed, for  the  distribution  of  the  dilated  vasa  vasis  proves  that  the  aortic 
free  ends  were  patulous,  and  we  have  further  proof  of  this  in  the  dilation  of 
the  aortic  ventricle  immediately  below  the  site  of  the  ligation. 

In  the  course  of  my  experiments  in  partial  occlusion  of  the  arteries  I  have 
often  studied  the  illustrations,  carefully  I  thought,  in  Luigi  Porta's  work, 
but  not  until  I  scanned  them  with  the  particular  object  in  view  did  I  dis- 
cover the  dilatations  so  strikingly  manifest.  I  wonder  if  anyone  has  ever 
commented  upon  or  been  interested  in  these  two  observations  of  Porta. 

The  following  summary  is  quoted  from  a  paper  read  at  the  annual  meet- 
ing of  the  National  Academy  of  Sciences  in  April  of  this  year. 

Summaey 

1.  A  partially  occluded  artery  (abdominal  aorta,  innominate,  carotid, 
subclavian )  may  dilate  distal  to  the  site  of  constriction. 

2.  The  dilation  is  circumscribed  and  has  been  greatest  when  the  lumen 
of  the  artery  (the  aorta)  was  reduced  to  about  one-third  or  perhaps  one- 
fourth  of  its  original  size. 

3.  When  the  obturation  has  been  slight  in  amount  dilation  has  not  been 
observed ;  of  7  cases  of  complete  obstruction  there  has  been  a  very  moderate 
degree  of  dilation  in  3  and  none  in  -i. 

10  Delle  alterazioni  patologiche  delle  arterie  per  la  legatura  e  la  torsione.  Milano, 
1845,  pp.  350,  Plate  V,  Figs.  3  and  5. 


468  DILATION  OF  COMMON  CAKOTID  AETERY 

4.  Complete  or  partial  occlusion  of  the  thoracic  aorta  may  be  followed 
by  dilation  central  to  the  point  of  constriction. 

5.  Dilation  or  aneurism  of  the  subclavian  artery  has  been  observed  twenty- 
seven  or  more  times  in  cases  of  cervical  rib. 

6.  The  dilation  of  the  subclavian  in  these  cases  is  circumscribed,  is  distal 
to  the  point  of  constriction  and  strikingly  resembles  the  dilation  which  we 
have  produced  experimentally. 

7.  The  dilation  of  the  artery  proximal  to  an  arteriovenous  fistula  and 
distal  to  a  partially  occluding  band  may  prove  to  be  referable  to  the  same 
cause. 

8.  When  the  lumen  of  the  aorta  is  considerably  constricted  the  systolic 
pressure  may  be  permanently  so  lowered  and  the  diastolic  pressure  so  in- 
creased that  the  pulse  pressure  may  be  diminished  by  one-half. 

9.  The  experimentally  produced  dilations  and  the  aneurisms  of  the  sub- 
clavian artery  in  cases  of  cervical  rib  are  probably  not  due  to  vasomotor 
paralysis,  trauma  or  sudden  variations  in  blood  pressure. 

10.  The  abnormal,  whirlpool-like  play  of  the  blood  in  the  relatively  dead 
pocket  just  below  the  site  of  the  constriction  and  the  lowered  pulse  pressure 
may  be  the  chief  factors  concerned  in  the  production  of  the  dilatation. 

11.  Bands,  rolled  ever  so  tightly,  do  not  rupture  the  intima. 

12.  Intimal  surfaces  brought,  however  gently,  in  contact  by  bands  or 
ligatures  do  not,  in  our  experience,  unite,  for  the  force  necessary  to  occlude 
the  artery  is  sufficient  to  cause  necrosis  of  the  arterial  wall. 

13.  The  death  of  the  arterial  wall  having  been  brought  about  by  the 
pressure  of  the  band,  a  gradual  substitution  of  the  necrotic  tissue  takes 
place,  the  new  vessels  penetrating  it  from  both  ends.  It  is,  I  believe,  in  this 
manner  that  an  artery  becomes  occluded,  and  it  is  thus  that  a  fibrous  cord 
forms  within  the  constricting  band. 


DILATION  OF  THE  GREAT  AETEEIES  DISTAL  TO  PAETIALLY 
OCCLUDING  BANDS ' 

The  incentive  to  the  work  was  primarily  the  desire  to  cure  aneurisms  of 
the  abdominal  aorta  and  common  iliac  arteries. 

The  method  usually  employed  for  the  cure  of  aneurism  is  the  simplest, 
viz.,  the  ligation  of  the  affected  artery  proximal  and  as  close  as  feasible  to 
the  aneurism.  The  aorta  has  been  ligated  25  or  more  times  in  man,  and 
always  with  fatal  result.  Death  has  been  due  to  haemorrhage  or  overtaxed 
heart.  Neither  gangrene  nor  paraphlegia  has  ever  resulted  from  ligation  of 
the  aorta  in  man.  We  found,  in  dogs,  as  was  to  have  been  expected,  that  fine, 
completely  occluding,  ligatures  (sizes  C  or  E  sewing  silk)  applied  to  the 
thoracic  aorta  just  below  the  arch  would  cut  through  in  about  two  days,  and 
invariably  with  promptly  fatal  haemorrhage;  whereas  coarse  ligatures 
usually  made  their  way  through  the  aortic  wall  very  slowly  and  without 
leakage  of  blood.  A  connective  tissue  diaphragm  often  forms  in  the  wake 
of  these  broader  threads  and  the  lumen  of  the  vessel  may  be  more  or  less 
completely  reestablished. 

It  occurred  to  me  after  much  experimentation  that  occlusion  of  the  aorta 
to  a  degree  not  sufficient  fatally  to  overburden  the  human  heart  might  effect 
the  cure  of  an  aortic  aneurism.  Knotted  ligatures  we  found  to  be  unsuitable, 
for  a  desired  degree  of  constriction  or  obliteration  could  not  be  accurately 
obtained  nor  could  the  crushing  of  the  arterial  wall  be  invariably  avoided. 
Tapes  of  various  materials  were  tested — of  cotton,  of  chromicized  intestinal 
submucosa,  of  elastic  tissue  obtained  from  the  aorta,  of  aponeurotic  white 
fibrous  tissue.  These  were  applied  in  spiral  or  cuff  form.  Best  suited  to  the 
purpose  were  bands  of  metal,  of  aluminum,  accurately  rolled  in  cylindrical 
form  by  a  little  instrument  of  this  kind  (exhibit).  In  the  use  of  these  metal 
bands  it  was  impossible  to  crush  the  arterial  wall,  and  the  desired  amount 
of  obturation  could  be  obtained  with  precision,  and  also  maintained. 

The  infolded  and  snugly  opposed  intimal  surfaces  under  the  compressing 
band  have  in  no  instance  adhered  to  each  other,  and  for  the  reason  that  the 
pressure  necessary  to  produce  even  a  very  slight  reduction  in  the  lumen  of 
the  vessel  has,  in  my  experience,  invariably  caused  atrophy  of  its  wall.  When 

1  Presented  before  the  National  Academy  of  Sciences,  Washington,  D.  C,  April  2, 
1918. 
Proc.  Nat.  Acad.  Sc,  Bait.,  1918,  iv,  204-210.   (Reprinted.) 

469 


470  DILATION  OF  GREAT  ARTERIES 

the  occlusion  is  complete  the  necrotic  arterial  wall  included  in  the  metal 
band  becomes  replaced  by  a  solid  cylindrical  cord  of  fibrous  tissue,  the  sub- 
stitution taking  place  from  the  ends. 

An  interesting  incidental  observation  which  we  have  made  in  the  course 
of  our  experiments  with  the  metal  band  is  this ;  that  a  dilation  of  the  artery 
occurs  just  below  a  band  when  the  degree  of  constriction  is  of  the  proper 
amount.  This  observation  apparently  explains  in  a  measure  the  occurrence 
of  aneurisms  of  the  subclavian  artery  distal  to  a  cervical  rib.  Analyzing 
525  clinical  cases  of  cervical  rib,  we  found  106  in  which  the  subclavian  artery 
had  been  compressed,  and  that  in  21  of  these  aneurism  or  dilation  of  this 
vessel  distal  to  the  site  of  constriction  had  been  noted. 

As  to  the  cause  of  these  aneurisms,  five  of  which  have  come  to  the  knowl- 
edge of  the  collators,  there  has  been  varied  conjecture.  Commentators  are, 
however,  agreed  that  the  occurrence  of  the  dilation  would  have  been  less 
incomprehensible  to  them  had  it  manifested  itself  on  the  proximal  instead 
of  the  distal  side  of  the  compression.  Attempts  have  been  made  to  explain 
the  phenomenon,  and  the  following  suggestions  offered  as  to  its  possible 
cause : 

(1)  Weakening  of  the  wall  of  the  subclavian  artery  from  erosion  by 
the  rib. 

(2)  Variable  or  intermittent  pulse  pressure  occasioned  by  the  normal 
excursions  of  the  arm. 

(3)  Vasomotor  and  vasa  vasorum  disturbances  leading  to  modified  nutri- 
tional activities  in  the  wall  of  the  artery. 

In  casting  about  for  an  explanation  of  these  aneurisms  there  constantly 
obtruded  itself  the  picture  of  the  dilated  arterial  trunks  which,  I  find  from 
the  study  of  about  400  cases,  has  occasionally  been  noted  on  the  cardiac 
side  of  arterio-venous  fistulae.  In  our  own  clinical  and  experimental  cases, 
dilation  of  the  artery  proximal  to  the  fistula  has  occurred  invariably.  For 
this  remarkable  manifestation,  likewise,  no  satisfactory  cause  has  been 
assigned.  There  might,  I  thought,  be  a  common  cause  for  both — for  the 
dilation  of  the  subclavian  artery  distal  to  the  cervical  rib,  and  for  the 
dilation,  central  to  the  arterio-venous  fistula,  of  the  artery  concerned  in  its 
formation.  Hence,  for  a  number  of  years,  in  the  course  of  various  experi- 
ments in  partial  occlusion  of  the  arteries,  I  had  somewhat  in  view  the  possi- 
bility of  the  production,  beyond  the  point  of  constriction,  of  a  dilation  of 
the  artery,  analogous  to  the  dilations  which  have  been  observed  in  cases  of 
cervical  rib. 

Four  years  ago  when  after  many  trials  I  had  altogether  despaired  of 
having  the  hope  realized,  I  was  startled,  on  examining  the  abdomen  of  a  dog 
whose  aorta  had  been  constricted  for  about  six  months  to  see  that  each  of 


PARTIALLY  OCCLUDING  BANDS  471 

the  branches  of  trifxircation  had  become  dilated  almost  to  the  size  of  the 
main  aortic  trunk. 

With  this  observation  as  incentive,  Dr.  Mont  Eeid  and  I,  the  following 
winter,  constricted  the  abdominal  aorta  just  above  its  trifurcation,  in  many 
dogs  and  at  intervals  explored  and  reexplored  the  abdominal  cavities,  but 
with  negative  result.  Finally,  on  investigating  the  abdomen  of  the  last  dog 
we  found  the  hoped-for  dilation.  The  degree  of  obturation  of  the  aorta  was 
accurately  determined  on  sacrificing  the  animal,  and  the  following  year  the 
experiments  were  more  advantageously  repeated  because  of  the  data  obtained 
from  this  case.  Xow,  that  we  have  apparently  determined  the  relative 
amount  of  constriction  required  to  give  the  most  pronounced  results  we  are 
able  in  almost  every  instance  to  produce  the  dilation. 

As  regards  the  cause  of  the  dilation  produced  experimentally  we  may, 
I  think,  conclude  that  it  is  not  to  be  found  in  any  of  the  three  factors  which 
have  been  proposed  as  responsible  for  the  dilation  observed  in  cases  of 
cervical  rib,  viz.,  (1)  vasomotor  paralysis,  (2)  trauma  and  (3)  variable 
blood  pressure. 

Ad.  1.  Vasomotor  Paralysis,  (a)  The  vasomotor  nerves  and  the  vasa 
vasorum  are  destroyed  by  the  moderately  constricting  and  totally  occluding 
bands  quite  as  surely  as  by  those  which,  occluding  almost  totally,  have  pro- 
duced the  greatest  amount  of  dilation,  (b)  Only  a  portion  of  the  circum- 
ference of  the  subclavian  artery  is  exposed  to  the  pressure  of  the  cervical  rib 
and  the  scalenus  anticus  muscle  and  hence  only  a  fraction  of  the  vasomotor 
nerves  or  vasa  vasorum  could  be  pressed  upon. 

Ad.  2.  Trauma,  (a)  The  dilation  is  usually  fusiform  and  distal  to  the 
rib.    (b)  Trauma  is  excluded  as  a  factor  in  the  experimental  dilations. 

Ad.  3.  Variable  Blood  Pressure,  (a)  Patients  suffering  from  the  pressure- 
pain  of  cervical  rib  rarely  make  wide  excursion  movements  of  the  arm. 
(b)  The  degree  of  occlusion  is  constant  in  the  experimentally  constricted 
vessel. 

When  an  arterial  trunk  is  ligated  it  becomes  occluded  to  the  first  proximal 
and  first  distal  branches  and  ultimately  reduced  to  a  fibrous  strand. 

From  observations  which  we  have  made  on  man  and  dogs  I  am  quite  sure 
that  there  may  be  a  remarkable  fall  in  blood  pressure  in  what  I  have  termed 
"  the  dead  arterial  pocket,"  while  there  is  still  little  if  any  sign  of  diminu- 
tion in  the  calibre  of  this  portion  of  the  vessel.  For  example,  the  right 
common  carotid  was  ligated  by  the  writer  in  a  case  of  aneurism  of  the 
external  carotid.  About  three  months  later,  in  the  course  of  an  operation 
for  the  excision  of  the  uncured  aneurism,  the  internal  carotid,  dead-pocketed 
between  the  circle  of  Willis  and  the  carotid  ventricle,  was  freely  exposed 
for  a  considerable  distance.   It  had  lost  its  cylindrical  form,  being  flat  and 


472  DILATION  OF  GREAT  ARTERIES 

tape-like,  and,  although  evidently  possessing  a  considerable  lumen,  seemed 
to  be  empty.  When  incised,  a  few  drops  of  blood  oozed  without  pulse  from 
the  little  cut.  The  artery  was  then  resected.  Its  wall  was  thickened  on  one 
side  but  the  lumen  was  still  perhaps  three  times  that  of  a  radial  artery. 
Similar  observations  I  have  made  twice  on  the  external  iliac  of  the  dog  after 
occlusion  of  this  vessel  at  its  origin  from  the  aorta.  In  the  dead  pocket 
between  the  aorta  and  the  origin  of  the  circumflex  iliac  and  common  trunk 
of  the  epigastric  and  obturator  arteries  the  blood  pressure  must  have  been 
almost  nil,  because  from  a  little  slit  in, the  apparently  normal  arterial  wall 
of  the  relatively  empty  external  iliac  artery  the  blood  escaped  very  slowly 
in  a  tiny,  almost  pulseless  jet  about  1  cm.  high;  whereas,  from  the  femoral 
artery,  below  the  profunda,  the  blood  spurted  normally  from  a  similar 
knife-prick. 

Hence  in  an  artery  doomed  to  obliteration,  it  would  seem  that  the  blood 
pressure  may  be  lowered  before  the  occlusion  process  sets  in — the  lowered 
pressure  being,  perhaps,  the  immediate  factor  leading  to  the  obliteration. 

Can  these  observations  have  any  bearing  upon  the  explanation  of  the  dila- 
tion of  the  aorta  above  its  trifurcation  and  of  its  triad  branches  in  the  dog 
after  partial  occlusion;  of  the  dilation  of  the  carotid  in  the  human  subject 
which  I  have  observed  in  one  case  after  partial  occlusion  of  the  innominate 
combined  with  ligature  of  the  first  and  third  portions  of  the  right  subclavian ; 
and  of  the  aneurism  of  the  third  portion  of  the  subclavian  in  cases  of 
cervical  rib  ? 

In  1906  Dr.  Richardson  and  I  made  the  observation  that  after  partial 
occlusion  of  the  thoracic  aorta  the  maximum  pressure  may  be  permanently 
lowered  and  the  minimum  pressure  permanently  increased  distal  to  the  con- 
stricting band ;  and  in  recent  experiments  Dr.  Reid  and  I  have  observed  that 
after  constriction  of  the  lower  abdominal  aorta  the  diastolic  pressure  may  be 
so  increased  and  the  systolic  pressure  so  lowered  as  to  reduce  the  pulse  pres- 
sure by  nearly  one  half.  The  blood  stream  in  this  case,  passing  with  greater 
velocity  and  less  pressure  through  the  band  prevents  the  obliteration  of  the 
artery  to  the  nearest  branch,  the  pocket  being  not  a  dead  one  as  it  is  in  the 
case  of  total  obliteration.  The  blood  in  this  pocket  beyond  the  constriction 
streams,  presumably,  in  whirlpools,  somewhat  as  in  the  vein  and,  also,  as 
in  the  artery  in  arterio-venous  fistula ;  the  thrill,  not  palpable  at  first  if  the 
occlusion  has  been  nearly  complete,  later  may  be  perceived  with  the  finger; 
and  the  bruit,  always  audible  with  the  stethoscope,  becomes  louder  as  the 
peripheral  arterial  resistance  increases. 

To  these  factors,  then — to  the  abnormal  play  of  the  blood  in  the  relatively, 
as  distinguished  from  the  absolutely  dead  pocket  and  to  the  absence  of 


PAETIALLY  OCCLUDING  BANDS  473 

normal  pulse  pressure,  essential  probably  to  the  maintenance  of  the  integrity 
of  the  arterial  wall,  we  may  have  to  look  for  the  solution  of  our  problem. 

We  have  completely  occluded  the  aorta  just  above  the  trifurcation  only 
in  dogs.  Usually  there  has  been  no  distal  dilation,  and  in  a  previous  paper 
I  made  the  statement  that  dilation  had  not  been  observed  below  a  totally 
occluding  band.  Since  then,  however,  a  slight  degree  of  dilation,  distal  to 
the  completely  obturated  vessel,  has  taken  place  in  three  instances.  A  dila- 
tion of  this  ventricle-like  portion  of  the  aorta  between  the  band  and  the 
trifurcation  might  be  expected  even  in  case  of  complete  occlusion,  for  the 
anastomosis  is  very  free  in  this  situation  and  the  dead  pocket  is  usually, 
and  perhaps  always  too  short  to  become  obliterated.  Lumbar  branches  may 
be  given  off  just  below,  as  they  are  just  above  the  band. 

In  two  instances  I  have  made  the  following  observation  in  testing,  during 
the  life  of  the  animal,  for  the  patency  of  the  aorta  under  the  band.  Pressure 
with  the  finger  immediately  above  the  band  shut  off  the  pulse  in  what  we 
term  the  ventricle;  whereas,  pressure  with  the  back  of  the  scalpel  blade, 
made  as  close  to  the  band  as  possible,  did  not.  In  these  cases  there  was  a 
patent  lumbar  artery  so  close  to  the  proximal  edge  of  the  band  that  pressure 
by  the  finger  obliterated  it,  whereas,  the  knife  blade  which  could  be  brought 
to  bear  on  the  aortic  wall  between  this  little  artery  and  the  upper  edge  of 
the  band  did  not  interrupt  the  flow  in  this  important  anastomotic  branch. 
The  contribution  of  this  little  artery  to  the  anastomotic  bloodstream  was 
sufficient  to  convert  an  impalpable  into  a  palpable  pulse.  A  palpable  pulse 
in  the  ventricle  below  the  band  is  so  invariable,  whether  the  aorta  has  been 
completely  occluded  or  not,  that  the  patency  of  the  artery  under  the  band 
cannot  be  definitely  determined  during  the  life  of  the  animal  unless  tem- 
porary occlusion  of  it  between  the  band  and  the  nearest  lumbar  artery  oblit- 
erates or  decidedly  influences  the  pulse  in  the  ventricle.  If  pressure  above 
the  band  does  not  affect  the  pulse  just  below  it  we  may  conclude  that 
obturation  is  complete. 

Fortunately  it  occurred  to  me  a  few  days  ago  to  restudy,  with  reference 
to  the  possibility  of  finding  depicted  a  dilation  of  an  artery  below  a  ligature, 
the  sketches  of  surgeons  who  in  bygone  years  had  experimentally  ligated 
the  blood  vessels  of  animals.  I  was  delightfully  surprised  to  find,  in  the 
beautifully  illustrated  volume  of  Luigi  Porta 2  published  in  1845  two  draw- 
ings which  portrayed  a  pronounced  dilation  of  the  aorta  and  its  ventricle 
immediately  below  the  site  of  ligation.  The  ligatures  in  the  two  dogs  had 
been  applied  eight  and  fifteen  months  before  the  death  of  the  animals.  There 

2  Luigi  Porta.  Delle  alterazioni  patologiche  delle  arterie  per  la  legatura  e  la  tor- 
sione.  Milano,  1845,  pp.  350,  351,  Plate  V,  Figs.  3  and  5. 


474  DILATION  OF  GREAT  AETEEIES 

is  a  great  bundle  of  dilated  vessels — the  vasa  vasis — bridging  the  gap  be- 
tween the  retracted  ends  of  the  diTided  aorta. 

Thus  three-quarters  of  a  century  ago  this  great,  perhaps  the  greatest 
surgeon  of  Italy,  furnished  irrefutable  proof  of  a  remarkable  phenomenon 
which  must  eventually  have  interest  for  the  physiologist,  the  pathologist 
and  the  surgeon.  Luigi  Porta  describes  the  drawing  but  makes  no  further 
comment  upon  the  dilation. 

Before  the  introduction  of  antiseptic  surgery  by  Lister,  thrombosis  quite 
invariably  followed  ligation  of  an  artery,  and  it  was  to  the  organization  of 
the  thrombus  that  the  surgeon  looked  for  the  prevention  of  secondary 
haemorrhage  and  for  the  preservation  of  the  life  of  the  patient.  If  thrombi 
formed  in  these  two  cases  of  Porta  they  must  have  been  eventually  absorbed, 
for  the  distribution  of  the  dilated  vasa  vasis  proves  that  the  aortic  free  ends 
were  patulous,  and  we  have  further  proof  of  this  in  the  dilation  of  the  aortic 
ventricle  just  below  the  site  of  the  ligation. 

In  the  course  of  my  experiments  in  partial  occlusion  of  the  arteries  I  have 
often  studied  the  illustration,  carefully  I  thought,  in  Luigi  Porta 's  work,  but 
not  until  I  scanned  them  with  the  particular  object  in  view  did  I  discover 
the  dilations  so  strikingly  manifest.  I  wonder  if  anyone  has  ever  commented 
upon  or  been  interested  in  these  two  observations  of  Porta. 

In  the  human  subject  I  have  in  one  instance  observed  a  remarkable  dila- 
tion of  an  artery  distal  to  a  partially  occluding  band.  In  this  case  an 
aluminum  band  was  applied  to  the  innominate  artery  for  the  cure  of  a  sub- 
clavian aneurism.  A  few  weeks  later,  the  aneurism  being  uninfluenced  by 
this  procedure,  the  subclavian  artery  was  ligated  both  proximal  and  distal 
to  the  sac,  and  a  cure  effected.  Three  years  later  a  quite  cylindrical  dilation 
of  the  right  common  carotid  was  observed;  and  now,  twelve  years  after 
the  application  of  the  band,  the  common  carotid  artery  is  strikingly  dilated 
throughout  its  entire  length.  The  band  on  the  innominate  can  be  palpated ; 
the  blood  is  coursing  through  it,  and  distal  to  the  band  is  a  distinct  bruit 
(exhibit). 

SuilMABY 

1.  A  partially  occluded  artery  (abdominal  aorta,  innominate,  carotid, 
subclavian)  may  dilate  distal  to  the  site  of  constriction. 

8.  The  dilation  is  circumscribed  and  has  been  greatest  when  the  lumen  of 
the  artery  (the  aorta)  was  reduced  to  one-third  or  perhaps  one-fourth  of 
its  original  size. 

3.  When  the  obturation  has  been  slight  in  amount  dilation  has  not  been 
observed;  of  T  cases  of  complete  obstruction  there  was  a  very  moderate 
degree  of  dilation  in  3,  and  none  in  4. 


PAETIALLY  OCCLUDING  BANDS  475 

4.  Complete  or  partial  occlusion  of  the  thoracic  aorta  may  be  followed  by 
dilation  central  to  the  point  of  constriction. 

5.  Dilation  or  aneurism  of  the  subclavian  artery  has  been  observed  twenty- 
seven  or  more  times  in  cases  of  cervical  rib. 

6.  The  dilation  of  the  subclavian  is  circumscribed,  is  distal  to  the  point 
of  constriction,  and  strikingly  resembles  the  dilation  which  we  have  pro- 
duced experimentally. 

T.  The  dilation  of  the  artery  proximal  to  an  arterio-venous  fistula  and 
distal  to  a  partially  occluding  band  may  prove  to  be  referable  to  the  same 
cause. 

8.  When  the  lumen  of  the  aorta,  is  considerably  constricted  the  systolic 
pressure  may  be  permanently  so  lowered  and  the  diastolic  pressure  so 
increased  that  the  pulse  pressure  may  be  diminished  by  one-half. 

9.  The  experimentally  produced  dilations  and  the  aneurisms  of  the  sub- 
clavian artery  in  cases  of  cervical  rib  are  probably  not  due  to  vasomotor 
paralysis,  trauma.,  or  sudden  variations  in  blood  pressure. 

10.  The  abnormal,  whirlpool-like  play  of  the  blood  in  the  relatively  dead 
pocket  just  below  the  site  of  the  constriction,  and  the  lowered  pulse  pressure 
may  be  the  chief  factors  concerned  in  the  production  of  the  dilation. 

11.  Bands,  rolled  ever  so  tightly,  do  not  rupture  the  intima. 

12.  Intimal  surfaces,  brought,  however  gently,  in  contact  by  bands  or 
ligatures  do  not,  in  our  experience,  unite  by  first  intention,  for  the  force 
necessary  to  occlude  the  artery  is  sufficient  to  cause  necrosis  of  the  arterial 
wall. 

13.  The  death  of  the  arterial  wall  having  been  brought  about  by  the  pres- 
sure of  the  band,  a  gradual  substitution  of  the  necrotic  tissue  takes  place, 
the  new  vessels  penetrating  it  from  both  ends.  It  is,  I  believe,  in  this  manner 
that  an  artery  becomes  occluded,  and  it  is  thus  that  a  fibrous  cord  forms 
within  the  constricting  band. 


CONGENITAL  ARTERIO-VENOUS  AND  LYMPHATICO-VENOUS 

EISTULAE.    UNIQUE  CLINICAL  AND  EXPERIMENTAL 

OBSERVATIONS  ' 

A.  Advance  of  a  Proximal  Arterial  Dilatation  Conformably  to  the  Trans- 
position, after  Operation,  of  the  Fistula. — Thanks  to  the  assistance  of 
highly  competent  secretaries  I  have  abstracts  of  about  400  cases  of  arterio- 
venous fistula.  These  have  been  studied  with  especial  reference  to  occa- 
sional observations  on  the  dilatation  of  the  arteries.  In  52  instances 
proximal  dilatation  of  the  arterial  trunk  has  been  noted.  I  am  quite  sure 
that  in  almost  every  instance  in  which  the  fistula  had  existed  for  two  or 
more  months  proximal  dilatation  of  the  artery  would  have  been  demon- 
strable if  looked  for. 

Congenital  arterio-venous  fistula  is  rare,  particularly  so  when  unasso- 
ciated  with  naevus.  We  have  been  able  to  find  reports  of  only  two  cases 
without  and  six  with  naevus.  Of  the  former  neither  was  cured,  unless  we 
except  the  case  of  von  Eiselsberg,  in  which  an  attempt  to  cure  a  fistula 
between  the  popliteal  artery  and  vein  was  followed  by  gangrene,  necessitat- 
ing amputation  of  the  thigh. 

The  following  case,  unique  in  several  particulars,  is  reported  to  record 
the  arterial  changes  observed  at  two  operations,  the  second  performed 
6^  years  after  the  first. 

The  patient,  a  girl  aet.  eleven  years,  was  operated  upon  by  the  author, 
November  15,  1911,  for  a  congenital  arterio-venous  fistula  below  the  angle 
of  the  jaw  on  the  right  side.  After  the  removal  of  a  tumor-like  mass  of 
enormously  dilated  veins  it  was  found  that  the  fistula  was  between  one  of 
these  and  the  external  carotid  artery  near  the  bifurcation  or  ventricle  of 
the  common  carotid.  Fortunately  a  careful  note  was  made  at  the  operation 
of  a  very  small,  anomalous,  ascending  branch  given  off  from  the  external 

1  Presented  at  the  Autumn  Meeting  of  the  National  Academy  of  Sciences  at  The 

Johns  Hopkins  University,  Baltimore,  November  8,  1918. 
Also  presented  at  the  American  Surgical  Association,  Atlantic  City,  N.  J.,  June 

16-18,  1919. 
Proc.  Nat.  Acad.  Sc,  Bait.,  1919,  v,  76-79.   (Reprinted.) 
Also:   Tr.  Am.  Surg.  Ass.,  Phila.,  1919,  xxxvii,  262.    (Reprinted.) 
Also:   Contrib.  Med.  &  Biol.  Research  ....  Sir  W.  Osier,  N.  Y.,  1919,  i,  560-567. 

(Reprinted.) 
476 


ARTERIO-  AXD  LYMPHATICO-VEXOUS  FISTULAE      477 

carotid  just  proximal  to  the  fistula  (vid.  Fig.  51).  There  was  great  dilata- 
tion of  the  common  carotid  and  of  the  external  carotid  arteries  proximal 
to  the  fistula,  whereas  the  internal  carotid  was  surprisingly  small.  The 
vessels  concerned  in  the  fistula  formation  were  excised,  the  aberrant  artery 
happily  being  spared.   The  child  was  relieved  of  very  distressing  symptoms 


Venous  sinus 


Aberrant  artery   -- 
drawn  aside 


Fig.  51. — Congenital  fistula  between  the  external  carotid  artery  and  a  large  vein. 
Appearances  at  the  first  operation.  Dilatation  of  the  common  and  external  carotid 
arteries  central  to  the  fistula,  and  of  the  venous  plexus.  The  internal  carotid  is 
abnormally  small.  There  is  a  tiny,  aberrant  branch  of  the  external  carotid. 


by  the  operation,  but  a  few  weeks  later  signs  of  a  second,  smaller  fistula 
developed,  at  a  distal  point,  just  below  and  in  front  of  the  ear.  A  second 
operation,  proposed  frequently,  was  not  acceded  to  until  last  spring,  6^  vears 
after  the  first.  At  this  operation,  performed  by  my  assistant,  Dr.  Mont 
Eeid,  in  my  presence,  remarkably  interesting  observations  were  made.  The 
tiny  aberrant  artery  had  become  dilated  almost  to  the  size  of  a  goose  quill, 


478      ARTERIO-  AND  LYMPHATICO-YENOUS  EISTULAE 

and  the  internal  carotid,  which  at  the  first  operation  was  strikingly  small, 
was,  we  estimated,  as  large  as  normal  (vid.  Eig.  52). 


Parotid  gland 
lifted  up 


Fig.  52. — Appearances  at  the  second  operation.  The  internal  carotid  and  the 
aberrant  branch  of  the  external  carotid  have  become  markedly  enlarged,  the  fistula 
having  shifted  its  position  to  a  peripheral  point. 


The  explanation  of  the  findings  is,  I  think,  clear.  There  were  originally 
two  fistulae.  The  chief  of  these  being  eliminated  at  the  first  operation,  the 
second,  distal  to  the  first,  functioned  more  and  more  freely  in  the  course 
of  the  6£  years.   The  internal  carotid,  small  at  the  operation,  being  central 


AETERIO-  AND  LYMPHATICO-VENOUS  FISTULAE      479 

to  the  main  fistula,  dilated  after  the  subordinate  or  distal  fistula  became 
active;  and  the  anomalous  artery,  also  central  to  the  main  fistula,  became 
dilated  for  the  same  reason.  In  regard  to  the  development  of  congenital 
arterio-venous  fistulae  Dr.  Florence  Sabin  has  kindly  written  me  as  follows : 

"  The  anomaly  of  direct  anastomoses  between  arteries  and  veins  brings 
up  an  interesting  point  in  the  development  of  the  vascular  system,  namely, 
that  vessels  which  have  served  as  arteries  in  the  embryo  may  become  veins 
and  vice  versa.  One  of  the  earliest  examples  of  this  occurs  in  the  develop- 
ment of  the  vessels  in  the  yolk  sac  of  the  chick.  Primitively  the  anterior 
half  of  the  yolk  sac  is  entirely  venous  while  the  posterior  half  is  entirely 
arterial,  thus  the  omphalo-mesenteric  vein  and  arteries  are  separated  as  far 
as  possible  by  a  wide  capillary  bed.  Subsequently  the  omphalo-mesenteric 
arteries  are  accompanied  by  veins  which  develop  as  follows.  As  can  be  seen 
in  Fig.  3,  Plate  3,  in  Popoff's  Atlas,3  originally  the  omphalo-mesenteric 
arteries  lie  throughout  their  course  in  a  capillary  network.  In  the  capillaries 
along  the  caudal  border  of  the  artery  the  blood  flows  away  from  the  heart, 
while  in  those  along  its  cephalic  border  it  returns  directly  to  the  heart. 
As  the  chick  develops,  these  two  sets  of  capillaries  along  the  main  stem  of 
the  artery  lose  their  connections  with  it  and  join  each  other,  thus  making 
a  plexus  which  accompanies  the  artery  and  receives  the  blood  which  has 
passed  out  to  the  tip  of  the  artery  and  returns  it  to  the  heart.  In  this  plexus 
develops  the  vein  which  accompanies  the  artery.  It  is  obvious  that  the 
retention  of  any  of  the  original  connections  of  these  capillaries  with  the 
artery  would  form  the  basis  of  a  direct  anastomosis  between  an  artery  and 
a  vein. 

"  In  connection  with  the  development  of  the  veins  of  the  head  and  neck, 
it  has  been  shown  that  the  internal  jugular  vein  develops  in  three  different 
segments.  At  first  the  blood  of  the  cerebral  veins,  which  make  the  first 
segment,  passes  through  a  long  vein  which  rests  on  the  hind-brain  and 
ultimately  becomes  a  plexus  of  vessels  in  the  pia  mater.  From  this  deep 
vein  the  blood  passes  into  the  third  segment,  which  is  the  anterior  cardinal 
vein,  and  thence  through  the  duct  of  Cuvier  to  the  heart.  This  deep  vein 
along  the  hind-brain  is  then  eliminated  from  the  drainage  of  the  cerebral 
veins  by  the  development  of  a  chain  of  capillaries  between  the  aorta  on  the 
one  hand  and  the  cerebral  veins  and  the  anterior  cardinal  vein  on  the  other. 
This  chain  of  capillaries  rapidly  enlarges  into  the  middle  segment  of  the 
internal  jugular  vein.  The  original  connections  with  the  aorta  are  shown 
injected  in  Fig.  1,  Plate  1,  Sabin  (1917),3  for  a  pig  embryo  with  23  somites, 
measuring  7  mm.  Moreover,  injections  of  pig  embryos  measuring  14  or 
15  mm.  may  still  show  slender  connections  between  this  middle  segment  of 
the  internal  jugular  vein  and  the  internal  carotid  artery. 

"  From  these  examples  it  is  obvious  that  the  details  of  the  origin  of  each 
vessel  should  be  worked  out  as  a  basis  for  specific  anomalies  that  may  occur 

2  Popoff,  D.,  1894,  "  Die  Dottersack-Gefasse,"  C.  W.  Kreidels  Verlag. 

3  Sabin,  F.  R.,  1917,  "  Origin  and  Development  of  the  Primitive  Vessels  of  the 
Chick  and  of  the  Pig."  Ibid.,  Contributions  to  Embryology,  No.  18,  Publication  226 
of  the  Carnegie  Institute  of  Washington. 


480      ARTERIO-  AND  LYMPHATICO-VENOUS  FISTULAE 

in  them,  as  has  not  yet  been  done  for  the  external  jugular  vein,  but  the 
underlying  principle  that  arteries  and  veins  develop  out  of  a  common  capil- 
lary plexus  forms  the  basis  for  the  persistence  of  direct  connections  between 
them." 

B.  Enlargement  of  the  Heart  in  Cases  of  Arterio-Venous  Fistula  and 
Persistent  Ductus  Arteriosus. — A  particularly  interesting  result  of  our 
clinical  and  experimental  studies  of  arterio-venous  fistula  is  the  discovery 
that  enlargement  of  the  heart  probably  occurs  after  a  time,  as  a  rule,  in  the 
major  cases.  Por  ten  years  or  more  we  have  noted  the  condition  of  the 
heart  in  our  patients  with  arterio-venous  fistula  and  have,  I  believe,  quite 
invariably  found  it  enlarged — strikingly  so  in  several  instances.  Dr.  Mont 
Reid,  of  our  Surgical  Staff,  has  in  preparation  a  report  upon  his  experi- 
mental and  clinical  work  on  arterio-venous  fistula  in  which  he  will  offer 
convincing  proof  of  our  view  that  the  fistula  in  its  consequences  may  pro- 
foundly affect  the  heart  as  well  as  the  veins  and  arteries.  Skiagraphs  show 
the  effects  of  a  fistula  made  3^  years  ago  by  Dr.  Reid  between  the  carotid 
artery  and  external  jugular  vein  of  a  dog.  The  veins  of  the  neck  on  both 
sides  are  dilated  and  the  carotid  artery  is  dilated  central  to  the  fistula.  The 
heart  after  two  years  showed  slight  enlargement,  and  now,  after  three  years, 
it  has  become  pronouncedly  increased  in  size.  If  the  assumption  is  correct 
that  the  heart  dilates  in  consequence  of  arterio-venous  fistula,  it  is  important 
that  the  fact  should  be  brought  to  the  attention  not  only  of  surgeons,  but 
also  of  pathologists  and  internists,  who  evidently  have  overlooked  it. 

Our  experimental  and  clinical  observations  on  arterio-venous  fistula  and 
partial  occlusion  of  large  arteries  may  ultimately  aid  in  the  explanation  of 
the  sequelae  of  certain  congenital  anomalies  of  the  heart  and  aorta.  May  we 
not  regard  the  persistent  ductus  arteriosus  as  an  arterio-venous  fistula,  the 
pulmonary  artery  and  the  right  heart  representing  the  venous  side  of  the 
fistula  ?  The  enlargement  of  the  left  heart  we  might  assume  for  the  moment 
to  be  somewhat  analogous  to  the  dilatation  of  the  artery  proximal  to  a 
fistula;  and  in  the  dilatation  of  the  right  heart  and  pulmonary  artery  we 
recall  the  dilatation  of  the  veins. 

My  studies  on  the  subject  of  the  dilatation  of  an  artery,  which  we  find 
occurs  distal  to  a  constricting  metal  band  and  distal  to  the  compression 
exercised  by  a  cervical  rib,  have  led  me  to  investigate  the  results  of  the 
congenital  coarctations  of  the  aorta  at  or  beyond  its  isthmus.  I  have  been 
interested  to  find  that  in  a  large  percentage  of  these  cases  of  coarcted  aorta 
there  is  dilatation,  more  or  less  delimited,  beyond  the  site  of  the  coarctation. 
The  generally  accepted  view  that  this  dilatation  is  to  enable  the  aorta  better 
to  carry  on  the  anastomotic  circulation  must,  it  seems  to  me,  be  erroneous. 
When  we  shall  have  ascertained  more  precisely  the  cause  of  the  arterial 


AKTEKIO-  AND  LYMPHATICO-VENOUS  FISTULAE      481 

dilatation  obtained  experimentally  below  constricting  bands  and  of  the 
dilatation  of  the  artery  proximal  to  an  arterio-venous  fistula,  we  may  be 
able  to  explain  the  dilatation  of  the  aorta  beyond  the  congenital  coarctation. 
C.  Plausible  Explanation  of  the  Presence  of  Blood  in  Lymph-Cysts  at  the 
Second  and  Subsequent  Tappings. — 

A  few  years  ago,  assisted  by  Dr.  Heuer,  I  removed  from  the  abdomen  of 
a  woman  about  forty  years  of  age  a  huge  congenital  hygroma  or  lymph- 
cyst.  The  diaphragm  was  pushed  high  up  into  the  right  thorax  and  the 
liver  was  displaced  far  to  the  right  and  so  rotated  on  its  vertical  axis  that 
its  inferior  border,  instead  of  being  transverse,  was  parallel  to  and  almost 
in  line  with  the  linea  alba.  The  enucleation  of  the  greater  part  of  the  cyst 
was  easily  accomplished,  the  few  adhesions  being  disposed  of  by  gentle, 
blunt  dissection.  Finally,  when  there  remained  only  a  few  filamentous 
fibers  binding  the  sac  to  the  right  adrenal  gland  *  and  the  inferior  vena  cava, 
we  proceeded  with  even  more  deliberation  and  caution.  The  adhesions  to 
the  vein  were  so  delicate  that  the  gentlest  manipulation  with  the  handle 
of  the  scalpel  sufficed  to  break  them.  We  had  an  unusually  free  and  clear 
exposure  of  the  vein  and  were  operating  without  embarrassment.  Suddenly 
blood  gushed  from  a  linear  defect  about  3  mm.  long  in  the  vena  cava.  The 
haemorrhage  was  promptly  controlled  and  the  slit  in  the  vessel  sutured. 
Proceeding  thereafter  with  perhaps  even  greater  delicacy,  we  were  again 
confronted  with  a  gush  of  blood  from  the  vena  cava  at  a  higher  point. 
Here  we  found  a  slit  about  1.5  cm.  long  in  this  vein.  The  edges  of  the  slit 
were  smooth,  the  linear  defect  being  clearly  not  due  to  a  tear  or  cut.  The 
gap  in  the  vein  was  closed  by  suture. 

Dr.  Heuer  and  I  satisfactorily  assured  ourselves  that  there  was  no  defect 
or  special  thinning  of  the  wall  of  the  cyst  at  the  point  contraposed  to  the 
larger  of  the  two  defects  in  the  wall  of  the  vena  cava.8 

The  defects  or  slits  were  surely  not  artefacts.  They  represented,  I  believe, 
imperfectly  closed  embryonic  communications  between  the  vein  and  lymph 
buds  or  lymphatic  vessels.  Dr.  Florence  Sabin,  to  whom  we  owe  so  much 
for  our  knowledge  of  the  origin  and  development  of  the  lymphatic  and 
vascular  systems,  writes  me  in  regard  to  this  case  as  follows : 

"  Eecent  work  on  the  lymphatic  system  serves  to  demonstrate  that  lym- 
phatic vessels  are  modified  veins.  It  has  been  shown  that  lymphatic  vessels 
occur  first,  in  the  neck  as  sacs,  lined  with  endothelium  and  packed  with 
blood,  which  lie  close  to  the  jugular  veins.  The  abdominal  lymphatics  begin 

4  The  relation  of  the  cyst  to  the  right  adrenal  gland  was  remarkable.  In  the  course 
of  stripping  the  sac's  final  delicate  attachments  we  exposed  a  flat,  black  surface, 
evidently  the  spread-out  medulla  of  the  adrenal,  about  the  size  of  a  half  dollar; 
parenchymatous  oozing  from  this  surface  required  for  its  arrest  a  few  mattress  sutures 
of  fine  silk. 

"The  patient  recovered  promptly  and  has  enjoyed  excellent  health  since  the  opera- 
tion. 

32 


482      AETEEIO-  AND  LYHPHATICO-VENOUS  FISTULAE 

as  a  sac  which  lies  close  to  that  part  of  the  inferior  vena  cava  which  con- 
nects the  two  Wolffian  bodies.  Baetjer "  showed  in  1908  that  in  the  pig  this 
sac,  which  is  the  forerunner  of  the  retroperitonaeal  lymphatics,  communi- 
cates for  a  time  with  the  inferior  vena  cava.  These  communications  between 
the  lymphatics  and  the  abdominal  veins,  which  are  transitory  in  the  pig, 
were  then  shown  to  be  permanent  in  the  South  American  monkeys  by 
Silvester  in  1912/  while  in  1915  Job s  demonstrated  similar  permanent 
connections  in  rodents.  Thus  the  study  of  the  development  of  the  lymphatic 
system  affords  an  explanation  of  anomalies  involving  connections  between 
the  lymphatic  vessels  and  both  the  renal  veins  and  the  inferior  vena  cava."  9 

The  statement  has  repeatedly  been  made  that  hygromata  which  at  the 
first  tapping  have  yielded  a  clear  fluid  may  be  found  at  all  subsequent  tap- 
pings to  contain  more  or  less  blood.  Only  one  explanation  has  been  offered 
for  the  presence  of  the  blood,  viz.,  trauma  of  the  wall  of  the  cyst.  This 
explanation  has  always  seemed  to  me  an  unsatisfactory  one,  because  the 
walls  of  these  cysts  are  as  a  rule  very  thin  and  nonvascular.  May  it  not,  in 
view  of  the  findings  in  our  case,  be  possible  that  vestigia  of  lymphatico- 
venous  communications  (vid.  Plate  XLII)  are  responsible  for  the  admix- 
ture of  blood  which  has  occasionally  been  noted  at  only  the  second  and 
subsequent  tappings  of  lymph-cysts  and  is  more  frequently  found  at  the 
first  tapping?  The  negative  pressure  consequent  upon  the  aspiration  of 
fluid  from  the  cyst  might  divert  for  the  moment  a  little  blood  from  the  vein 
which  had  given  origin  to  the  hygroma's  lymphatic  bud  or  vessel.  Thus 
the  contents  of  the  sac,  clear  at  the  first  withdrawal,  would  be  blood-stained 
at  the  second.  Thereafter,  with  each  tapping  blood  would  be  aspirated  into 
the  sac  and  hence  clear  fluid  might  never  again  be  obtained. 

"Baetjer,  W.  A.,  1908,  "  On  the  Origin  of  the  Mesenteric  Sac  and  the  Thoracic  Duct 
in  the  Embryo  Pig."   Am.  J.  Anat.,  viii. 

7  Silvester,  C.  F.,  1912,  "  On  the  Presence  of  Permanent  Communications  Between 
the  Lymphatic  and  Venous  Systems  at  the  Level  of  the  Renal  Veins  in  Adult  South 
American  Monkeys."   Am.  J.  Anat.,  xii. 

*  Job,  T.  T.,  1915,  "  The  Adult  Anatomy  of  the  Lymphatic  System  in  the  Common 
Rat,"  Anat.  Rec,  ix. 

'Sabin,  F.  R.,  1913,  "The  Origin  and  Development  of  the  Lymphatic  System," 
Johns  Hopkins  Hosp.  Rep.,  Monographs,  New  Series,  No.  v. 

Ibid.,  1915-1916,  "  The  Method  of  Growth  of  the  Lymphatic  System."  The  Harvey 
Lectures,  Series  xi,  J.  B.  Lippincott  Co. 


PLATE    XLII 


•  Si         <" 


a^ 


t     3 

i  i 


LIGATIONS  OF  THE  LEFT  SUBCLAVIAN  ARTERY  IN  ITS 
FIRST  PORTION1* 

In  a  delightful  discourse  **  on  arterio-venous  aneurism  Osier  takes  a  swift 
flight  into  a  vibrant  domain  of  surgery,  tracing  into  and  out  of  the  dark 
ages  steps  of  the  few  surgeons  who  blazed  the  way.  Well  he  knew  and  loved 
the  crystal  springs  and  sources  bearing  their  tiny  freights  of  knowledge  to 
the  flood.  Readers  of  The  Johns  Hopkins  Hospital  Reports  will  welcome 
the  quotation  from  Sir  William's  paper : 

"  Better  than  any  other  disease  aneurysm  illustrates  how  borderless  are 
the  boundaries  of  medicine  and  surgery.  Here  am  I  talking  on  the  most 
surgical  of  all  its  aspects,  while  very  likely  not  far  away  a  surgeon  is  prac- 
tising the  best  possible  prevention  against  internal  aneurysm  in  giving  a 
syphilitic  patient  an  injection  of  salvarsan !  Aneurysm  has  been  a  medico- 
chirurgical  affection  ever  since  some  bungling  young  '  minutor  '  first  nicked 
the  brachial  artery  in  performing  venesection.  One  of  the  earliest  and  most 
interesting  references  in  literature  is  to  an  instance  of  this  kind.  Galen  was 
called  in  consultation  by  a  young  and  inexperienced  surgeon  who  had  opened 
the  artery  at  the  bend  of  the  elbow  instead  of  the  vein,  and  the  blood  spurted 
out '  clarus,  rubens,  lucidus  et  calidus.' 

'I  took  in  the  situation  at  once;  there  happened  to  be  an  elderly  physician  with 
me,  so  we  prepared  a  medicine,  viscid,  conglutinable,  and  obstructive,  and  placing 
it  strongly  against  the  lips  of  the  wound  bound  over  it  a  soft  sponge.  The  surgeon 
who  had  opened  the  artery  wondered,  but  said  nothing.  When  we  went  out  [note 
the  professional  touch!]  I  said  to  the  surgeon  that  he  had  opened  the  pulsating 
vessel  and  charged  him  not  to  dress  the  wound  before  the  fourth  day,  and  not 
without  me.' 

"  The  cure  was  complete,  and  Galen  remarks  that  this  was  his  only  suc- 
cessful case  of  the  kind,  as  in  all  others  aneurysm  had  followed.  This 
account,  taken  from  Symphorien  Campegius  Claudii  Galeni  Pergameni 
Historiales  Campi,  Basilae,  1532,  p.  43,  is  doubtless  of  the  case  referred  to 
in  the  Methodus  Medendij  The  only  other  references  to  aneurysm  in  Galen 
are  in  the  Be  Tumoribus  praeter  Naturam  \  and  in  the  He  Curandi  Ratione 
per  Sanguinis  Missionem,  §  in  which  he  refers  to  the  possibility  of  gangrene. 

Histoeical  Survey 

"  Rational  surgery  was  one  of  the  gifts  of  the  Greeks,  but  in  the  800  years 
between   Hippocrates   and   Oribasius  few   names   have   survived   specially 

11  Received  for  publication  June  26,  1920. 

Johns  Hopkins  Hosp.  Rep.,  Bait.,  1921,  xxi,  1-96.    (Reprinted.) 

t  "  Linacre's  edition,  1517,  f.  lxii,  v." 

t "  Junta,  fifth  edition,  1576,  iii,  p.  84." 

§  "Ibid.,  vi,  p.  21." 


484  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

associated  with  this  branch  of  medicine.  Who  among  us  off-hand  could 
recall  more  than  two  or  three  in  addition  to  Hippocrates  and  Galen?  Yet 
in  this  period  scores  of  important  schools  flourished  with  great  teachers  of 
surgery,  men  honoured  in  their  generation  and  the  glory  of  their  times. 
As  one  reads  the  partial  list  in  Haller's  Bibliotheca  Chirurgica  and  scans 
the  few  golden  remains  of  their  writings  fortunately  preserved  by  encyclo- 
paedists such  as  Oribasius  and  Paul  of  Aegina,  the  truth  of  Sir  Thomas 
Browne's  remarks  comes  home :  '  Who  knows  whether  the  best  of  men  be 
known,  whether  there  be  not  more  remarkable  persons  forgot  than  any 
that  stand  remembered  in  the  known  account  of  time  ? '  Two  of  these  com- 
paratively unknown  men  created  the  surgery  of  arteries,  Rufus  of  Ephesus 
and  Antyllus,  the  Cosmas  and  Damien  of  Greek  surgery.* 

KUFUS    OF   EPHESUS 

"  To  generations  of  practitioners  unworthy  to  hand  him  ligatures  Eufus 
of  Ephesus  (Reign  of  Trajan,  early  part  of  second  century  A.  D.)  was 
known  by  the  *  pilulae  Ruffi,'  '  the  pills  I  would  not  be  without ' — '  pilulae 
sine  quibus  esse  nolo ' — still  in  the  British  Pharmacopoeia  as  the  pill  of 
aloes  and  myrrh.  In  the  brilliant  Ionian  profession  of  the  early  days  of  our 
era  Rufus  doubtless  had  predecessors  and  teachers,  but  he  stands  out  a 
strong,  clear  figure,  a  great  '  magister  chirurgiae,'  a  title  justly  earned  by 
his  remarkable  contribution  to  the  surgery  of  haemostasis.  We  know  it  only 
through  a  section  in  Aetius,  a  sixth-century  physician. f  Nothing  is  lacking 
in  a  description,  which  might  be  transferred  to  any  modern  textbook — 
digital  compression,  styptics,  the  cautery,  torsion,  and  the  ligature — only 
I  am  sorry  not  to  find,  as  is  sometimes  said,  a  description  suggestive  of 
arterio-venous  aneurysm,  though  he  speaks  of  the  possibility  of  traumatic 
aneurysm. 

"  Through  the  Arabians  the  name  of  Rufus  was  on  the  lips  of  every 
mediaeval  physician,  and  we  find  him  among  the  favorites  of  Chaucer's 
well-read  Doctor.  In  one  of  the  earliest  and  most  beautiful  of  medical 
manuscripts,  the  famous  Juliana  Anicia  Dioscorides  (A.  D.  525),  of  the 
Vienna  Library,  he  is  figured  with  Galen,  Hippocrates,  and  others. 

ANTYLLUS 

"  Upon  the  other  great  surgical  figure  of  antiquity,  Antyllus,  so  blindly 
has  oblivion  scattered  her  poppies,  to  quote  Sir  Thomas  Browne  again, 
that  not  a  fact  of  his  life  is  known ;  yet  through  the  mists  of  18  centuries  he 
looms  large  as  one  of  the  most  daring  and  accomplished  surgeons  of  all  time. 
A  resector  of  bones  and  joints,  one  of  the  first  to  perform  tracheotomy,  the 
founder  of  the  surgery  of  fistula,  a  successful  operator  upon  cataract,  and 

*  "  These  practitioners,  who  became  the  Christian  saints  of  surgery,  suffered  mar- 
tyrdom in  Cilicia  in  the  third  century.  In  their  Western  Mother  Church,  on  the 
Roman  Forum,  I  have  seen  the  little  parcel  said  to  contain  the  instruments  with 
which  they  performed  the  most  famous  operation  in  hagiological  surgery,  substitu- 
tion of  the  healthy  thigh  of  a  just-dead  man  for  one  that  was  gangrenous." 

t  "  Tetrabiblos,  lib.  xiv,  cap.  51." 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  485 

we  may  say  the  creator  of  the  surgery  of  the  arteries — these  are  among  his 
known  achievements.  His  remains  are  chiefly  in  the  works  of  Oribasius,  the 
physician  and  friend  of  the  Emperor  Julian. 

"  Nowhere  are  we  impressed  with  the  note  of  directness  so  characteristic 
of  the  Greek  (see  R.  W.  Livingstone's  Meaning  of  the  Greek  Genius,  second 
edition,  1915)  as  in  the  brilliant  account  given  by  this  author  of  aneurysm, 
of  which  he  was  the  first  to  recognise  two  forms — one  by  dilatation,  the 
other  following  wound  of  the  artery.  So  far  as  I  can  gather,  he  was  also 
the  first  to  describe  the  thrill  or  bruit  so  characteristic  of  the  latter  form. 
No  ancient  writer  has  anything  like  the  same  accuracy  of  pathological 
description,  and  you  may  search  the  surgical  literature  for  centuries  before 
there  is  found  such  a  gem  as  the  account  of  his  method  of  operation  still  in 
use,  and  by  which  his  name  has  been  permanently  enshrined.  Not  finding 
one  in  English,  I  asked  Mr.  Livingstone,  of  Corpus  Christi  College,  to  give 
us  a  complete  translation  of  the  fragment. 

About  Aneurisms  (From  the  Works  of  Anttllus  *) 

'  There  are  two  different  kinds  of  aneurysms.  The  one  kind  occurs  when  there  is 
a  local  dilatation  of  an  artery  (this  was  the  origin  of  the  name  aneurysm  or  dilata- 
tion). The  other  kind  arises  from  the  rupture  of  an  artery  and  the  discharge  of  the 
blood  into  the  flesh  beneath  it.  Aneurysms  due  to  the  dilatation  of  an  artery  are 
longer  than  others;  those  due  to  a  rupture  are  rounder.  In  the  former  there  is  a 
thicker  layer  of  tissue;  in  the  latter  you  can  hear  a  certain  crepitation  if  you  press 
them  with  your  finger;  while  in  aneurysms  due  to  dilatation  there  is  no  sound. 

'  It  is  foolish  to  follow  the  practice  of  the  ancient  surgeons  and  decline  to  treat 
any  aneurysm,  but  it  is  dangerous  to  apply  surgical  treatment  to  all  types.  Se  we  will 
excuse  ourselves  from  treating  aneurysms  in  the  armpit,  groin,  and  neck,  on  the  ground 
that  the  vessels  are  large  and  that  it  is  impossible  or  dangerous  to  isolate  and  tie 
them.  We  also  decline  exceptionally  big  aneurysms,  even  if  they  occur  elsewhere. 
But  we  will  operate  as  follows  on  aneurysms  in  the  extremities,  the  limbs  and  the  head. 

'  If  the  aneurysm  results  from  dilatation,  we  will  make  a  straight  incision  in  the 
skin  the  whole  length  of  the  vessel;  then,  after  separating  the  edges  of  the  incision 
with  hooks,  we  will  carefully  sever  all  the  membranes  between  the  skin  and  the  artery. 
Then  pushing  aside  with  blunt  hooks  the  vein  adjacent  to  the  artery,  we  will  expose 
the  dilated  portion  of  the  artery  on  all  sides.  Next,  we  will  introduce  the  head  of  a 
probe  underneath,  and,  lifting  the  aneurysm,  insert  along  the  probe  a  needle  with  a 
double  thread,  so  that  it  passes  beneath  the  artery.  We  will  cut  the  threat  at  the 
eye  of  the  needle,  making  two  threads  and  four  ends  of  thread;  then,  taking  the  two 
ends  of  one  of  the  threads,  we  will  pass  them  gently  to  one  end  of  the  aneurysm 
and  tie  them  with  precision.  Similarly,  we  will  pass  the  other  thread  to  the  opposite 
end  of  the  aneurysm,  and  then  tie  up  the  artery,  so  that  the  entire  aneurysm  lies 
between  the  two  "ligatures.  Then  we  will  lance  the  aneurism  with  a  small  incision 
at  its  centre;  in  this  way  its  contents  will  all  be  evacuated  without  any  danger  of 
haemorrhage.  Those  who  tie  the  artery,  as  I  advise,  at  each  extremity,  but  amputate 
the  intervening  dilated  part,  perform  a  dangerous  operation.  The  violent  tension 
of  the  arterial  pneuma  often  displaces  the  ligatures. 

'  If  the  aneurysm  originates  in  the  rupture  of  an  artery,  isolate  with  your  fingers 
as  much  of  the  aneurysm  as  you  can,  including  the  skin.    Then  below  the  isolated 


part  introduce  a  needle  with  a  double  thread  of  flax  or  of  gut ;  after  passing  it 
through,  cut  it  at  the  needle's  eye  forming  two  threads.  Take  hold  of  the  two  ends 
of  one  of  these  and  pass  it  to  the  right,  there  tie  it  tightly,  so  as  not  to  slip.   Pass 


the  other  end  similarly  in  the  opposite  direction — to  the  left.  If  there  is  any  fear 
of  the  threads  slipping,  pass  a  second  needle  with  a  similar  double  thread  through 
the  same  spot,  intersecting  the  first  thread  and  crossing  it  in  the  form  of  the  letter  X 

♦"Oribasius,  iv.,  p.  52   (ed.  Daremberg)." 


486  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

(chi).  Cut  the  threads  as  before,  and  tie  them  like  the  first  ones,  so  that  four  threads 
form  the  ligature.  Then  open  the  tumour  at  its  top,  and,  after  evacuating  the  con- 
tents, remove  the  superfluous  skin,  leaving  the  part  tied  by  the  threads.  In  this  way 
the  operation  is  effected  without  haemorrhage.' 

"  And  I  must  read  Mr.  Livingstone's  comment : 

'  It  certainly  is  a  beautiful  piece  of  lucid  writing.  I  felt  that  if  I  was  alone  on  a 
desert  island  with  someone  suffering  from  aneurysm,  and  the  tide  had  washed  ashore 
sufficient  ayKcarpa,  etc.,  that  I  shouldn't  have  minded  trying  the  operation.  And 
Antyllus  had  real  literary  power.  What  an  admirable  phrase  is  eKirrverai,  the  "  spit- 
ting out  "  of  the  ligature  by  the  throbbing  artery :  I  don't  think  you  can  get  it  in 
English,  and  I  fell  back  on  a  lame  substitute,  "  displaces." '  * 

"  Not  unjustly  does  Paul  Broca  in  his  great  monograph,  Des  Anevrismes, 
claim  that  not  only  did  Antyllus  create  operative  medicine  but  the  pathology 
of  aneurysm :  '  A  chaque  ligne  on  reconnait  l'ecrivain  qui  parle  de  ce  qu'il 
a  fait.' 

Decay  and  Revival  of  Vasculak  Surgery 

"  Aetius  in  the  middle  of  the  sixth  century  describes  the  method  for  cure 
of  aneurysm  at  the  elbow,  known  later  as  that  of  Anel  (1710),  ligation  of 
the  brachial  artery  three  or  four  fingers'  breadth  below  the  axilla,  followed 
by  opening  the  sac,  which  was  allowed  to  heal  by  suppuration.  A  curious 
error  of  Sprengel  has  led  to  the  connexion  of  the  name  of  Philagrius,f 
a  fourth  century  surgeon,  with  this  operation.  In  the  fragments  of  this 
writer  given  by  Aetius  aneurysm  is  not  mentioned,  but  Sprengel  never 
noticed  that  the  extract  on  aneurysm  which  follows  directly  after  one  upon 
ganglion  by  Philagrius  did  not  belong  to  this  author  but  to  Aetius  himself. 

"  A  casual  perusal  of  the  fragments  of  the  Greek  surgeons  of  the  first 
three  or  four  centuries  of  our  era  as  given  in  Gurlt's  Geschichte  der  Chirur- 
gie  gives  the  impression  of  a  great  and  fruitful  period  with  scores  of  men 
whose  qualifications  were  those  demanded  by  Thomas  Fuller  for  the  good 
operator — the  eagle's  eye,  the  lion's  heart,  and  the  lady's  hand.  Then  came 
the  tragedy,  the  death  in  the  West  of  the  science  of  the  Greeks.  The  Church 
took  over  their  philosophy,  the  Arabs  absorbed  much  of  the  best  of  their 
medicine  and  added  to  it,  but  surgery  as  a  progressive  science  and  a  suc- 
cessful art  died  with  its  founders,  the  great  Greeks  of  the  Graeco-Roman 
Empire.  So  far  as  the  surgery  of  arteries  is  concerned  we  might  take  a 
jump  of  a  thousand  years  or  more  were  it  not  for  an  Arabian,  Albucasis  of 
Cordova  (tenth  century),  who  wrote  a  famous  surgical  treatise,  of  which  we 
have  in  the  Bodleian  the  two  earliest  manuscripts.  A  young  scholar  of 
Wadham  and  Student  of  Christ  Church,  John  Channing,  in  1778  issued 

*  "  Blows  off  "  might  serve — the  expression  fits  the  conception  of  air  (irvt7fj.a)  in 
the  arteries.  But  it  is  difficult,  as  Mr.  Livingstone  remarks,  to  improve  upon  "  spits 
off,"  for  to  spit  one  inflates  the  lungs.    (W.  S.  H.) 

t  The  method  ordinarily  attributed  to  Philagrius  is  the  one  practised  by  Purmann  ** 
(1680) — an  aneurismectomy.  For  the  seemingly  final  word  on  the  subject  of  the 
operations  for  aneurism  of  Philagrius  and  Antyllus  the  reader  is  referred  to  the 
illuminating  paper  of  Kbhler.28  It  would  lead  us  too  far  afield  to  follow  him  through 
the  mazes  of  the  discussion  or  even  to  indicate  the  ramifications  of  the  contradictions 
found  in  the  most  authentic  documents.  We  must  for  the  present  accept  the  con- 
clusions reached  by  this  painstaking  scholar.    (W.  S.  H.) 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  487 

from  the  Clarendon  Press  a  beautiful  edition.  The  description  which  he 
gives  of  aneurysm  with  its  treatment  is  practically  that  of  Antyllus.  He 
notes  the  stridor  to  be  felt,  which  indicates  that  he  was  probably  dealing 
with  the  arterio-venous  form. 

"  In  vascular  surgery  the  men  of  the  Middle  Ages  and  of  the  Renaissance, 
Henri  de  Mondeville,  Guy  de  Chauliac,  and  even  Ambroise  Pare,  were  blind 
followers,  who  never  even  approached  the  position  of  their  masters.  Not 
much  more  than  a  century  has  passed  since  men  of  the  John  Hunter  type 
took  up  vascular  surgery  where  Rufus  and  Antyllus  had  left  it.  You  may 
think,  perhaps,  that  I  am  scarcely  just  to  the  great  mediaeval  surgeons,  par- 
ticularly to  such  a  master  as  Ambroise  Pare,  who  reintroduced  the  ligature, 
but  in  vascular  surgery,  the  touchstone  of  the  position  of  the  art,  they  never 
wholly  regained  what  the  profession  had  lost."  * 

What  surgeon  called  upon  to  treat  a  huge  aneurism  of  the  neck  or  groin 
has  not  experienced  the  disturbing  sensations  which  only  such  tumors  can 
arouse  ?  When  confronted  with  an  inoperable,  malignant  neoplasm  one  feels 
the  great  pity  of  it  but  not,  as  in  the  case  of  an  aneurism,  a  peremptory  chal- 
lenge to  face  the  exigency  and  cope  promptly  with  a  situation  demanding 
skilful,  resourceful,  and  possibly  even  temerous  intervention.  Few  of  the 
surgeons  to  come  will  have  occasion  to  be  stirred  as  Valentine  Mott  must 
have  been  by  his  dramatic  experience  in  ligating  the  common  iliac  artery. 
The  surgeon  of  today  looks  rather  to  science  than  to  his  art  for  stimulating 
rewards  of  his  endeavor.  In  ligating  the  first  portion  of  the  left  subclavian 
within  the  chest  the  operator  may  not,  as  formerly,  be  more  greatly  im- 
pressed by  the  magnitude  and  cleverness  of  his  performance  than  by  the 
miraculous  effect  of  the  ligation  of  the  artery  upon  the  great,  pulsating 
tumor  which  with  each  beat  of  the  heart  jarred  the  whole  frame  of  the 
sufferer.  The  moment  of  tying  the  ligature  is  indeed  a  dramatic  one.  The 
monstrous,  booming  tumor  is  stilled  by  a  tiny  thread,  the  tempest  silenced 
by  the  magic  wand. 

We  have  reports  of  several  aneurisms  of  the  subclavian  artery  which  may 
have  been  quite  as  large  as  the  one  which  I  am  about  to  record,  but  no  one 
of  these  was  operated  upon. 

Huge  Subclavian  Aneurism.   Ligation  of  the  First  Portion  of  the 

Left  Subclavian  Artery,  and,  Two  Years  Later,  Excision 

of  the  Contracted  Tumor 

Sur.  No.  46179.  Alexander  Miller.  Negro,  aet.  29.  Admitted  to  The 
Johns  Hopkins  Hospital,  April  22,  1918 ;  discharged  August  12,  1918. 

The  patient  states  that  he  has  always  been  perfectly  well.  In  April,  1917, 
he  noticed  a  swelling  about  the  size  of  an  egg  above  the  left  clavicle.  Almost 

*  True  also  it  is,  as  I  have  often  said,  that  the  surgeon's  method  of  dealing  with  the 
blood  vessels  is  a  criterion  of  his  proficience  in  his  art.    (W.  S.  H.) 


488  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

simultaneously  with  the  recognition  of  the  swelling,  pain  and  numbness  in 
the  upper  extremity  were  observed.  The  growth  of  the  tumor  was  gradual 
until  about  March,  1918 ;  since  then  it  has  been  very  rapid.  For  the  past 
two  weeks  the  limb  has  been  totally  paralyzed.  The  patient  recalls  that 
until  Christmas,  1917,  he  could  still  raise  his  arm  a  little. 

About  four  years  before  admission  the  patient  was  shot  just  above  the 
left  clavicle.  The  wound  healed  promptly.  The  bullet  was  not  removed  and 
has  given  him  no  indication  of  its  presence. 

Examination. — The  patient  is  evidently  suffering  severe  pain,  and  con- 
stantly supports  his  left  wrist  with  his  right  hand.  The  pain,  he  says,  is 
most  intense  from  the  elbow  joint  to  the  hand  and  in  the  left  shoulder. 

A  huge  aneurism  occupies  the  left  neck  from  the  clavicle  to  the  ear 
(Plate  XLIII,  1  and  2).  The  head  is  deflected  and  rotated  to  the  right. 
The  vertex  of  the  pulsating  mass  is  about  on  a  plumb-line  dropped  to  the 
junction  of  the  middle  and  inner  thirds  of  the  clavicle.  The  swelling  and 
pulsation  extend  on  to  the  chest,  and  the  whole  body  is  jarred  with  each 
heartbeat.  Posteriorly  the  diffuse  pulsating  tumefaction  spreads  out  to  a 
point  below  the  spine  of  the  scapula.  The  aneurism  extends  upward  in  dome- 
shape  :  a  hand  can  be  inserted  between  it  and  the  face  down  to  the  angle  of 
the  lower  jaw.  The  whole  shoulder-girdle  appears  to  be  raised  away  from 
the  chest  wall,  the  acromioclavicular  articulation  being  apparently  dis- 
rupted. The  skin  over  the  tumor  is  extremely  tense  and  glistening.  From 
the  clavicle  to  about  the  level  of  the  nipple  the  brawny  tissues  are  probably 
infiltrated  with  blood  as  well  as  inflammatory  products.  The  trachea  is 
displaced  to  the  right.  A  systolic  bruit,  most  distinct  above  the  inner  third 
of  the  clavicle,  can  be  heard  over  the  greater  part  of  the  pulsating  mass. 
No  thrill  can  be  felt.  The  left  radial  pulse  is  absent.  There  is  slight  ptosis 
of  the  left  eyelid,  but  the  pupils  seem  to  respond  equally.  Only  the  inner 
third  and  the  acromial  tip  of  the  clavicle  can  be  defined  with  the  fingers; 
the  remainder  of  the  bone  is  buried  in  the  tumefaction.  A  bullet  is  palpable 
just  beneath  the  skin  to  the  left  and  below  the  spine  of  the  seventh  cervical 
vertebra.  The  muscles  of  the  left  shoulder,  arm,  and  forearm  are  paralyzed ; 
there  remains  a  trace  of  power  to  flex  the  fingers  and  wrist.  The  deep 
reflexes  are  absent  and  the  muscular  atrophy  is  marked.  The  entire  extrem- 
ity up  to  and  over  the  aneurism  is  insensitive  to  touch,  pin-prick,  and 
temperature. 

Fluoroscopic  Examination. — The  shadow  of  the  aneurism  extends  to  the 
lower  border  of  the  clavicle  but  not  to  the  first  rib.  The  heart  seems  not 
to  be  enlarged.  The  right  subclavian  and  carotid  arteries,  distinctly  seen, 
are  normal  in  size. 

Sl-iagraphic  Report. — Large  mass  in  left  neck.  Clavicle  deeply  eroded, 
perhaps  fragmented.  Bullet  in  upper  dorsal  region. 

The  thought  of  excising  or  incising  the  aneurism  was  hardly  entertained. 
The  patient's  condition  contraindicated  such  a  prolongation  of  the  inter- 
vention, and  an  operation  on  so  large  a  scale  and  through  so  great  an  expanse 
of  infiltrated  and  inflamed  tissues  might  have  menaced  from  infection  the 
life  of  the  patient  and  have  imperiled  the  artery  at  the  site  of  the  ligature, 
deep  within  the  thorax. 


PLATE   XLIII 


1. — Aneurism  of  the 


rv.  Alexander 


Miller.  April  22.   191S 


2.— Alexander  Miller.  April  22.  1918. 


PLATE   XLIV 


1 —Alexander  Miller.  109  day?  after  ligation  of  the  sub- 
clavian artery  near  its  origin. 


2     Alexander  Miller,  km  daya  after  the  ligation. 


PLATE  XLV 


1. — Alexander  Miller,  10  months  after  the  li 


2. — Alexander  Miller,  10  months  after  the  ligation. 


PLATE   XLVI 


1. — Alexander  Miller,  2  years  after  the  ligation  of  the 
subclavian,  and  2  weeks  before  the  excision  of  the 
ineurism. 


2      Alexander    Miller,    l    month    after   excision   of   the 
aneurism. 


LIGATION  OF  LEFT  SUBCLAVIAN  AETEEY  489 

Operation,  April  26,  1918. — Dr.  Halsted.  Ligation  of  the  left  common 
carotid  and  the  left  subclavian  arteries  near  their  origin  from  the  aorta. 

Ether.   Wide  protection  of  the  operative  field  with  celloidin  silk.20 

Transverse  bow-incision  just  below  the  cervicothoracic  junction,  supple- 
mented by  a  vertical  one  along  the  left  border  of  the  sternum  (bow  and 
plummet  incision).  Free  exposure  of  manubrium  and  left  sternoclavicular 
joint.  The  incised  tissues  were  oedematous,  particularly  so  below  the  clav- 
icle. The  superficial  vessels  were  abnormally  large.  Careful  haemostasis  by 
the  fine  silk  transfixion  method.  The  left  two-thirds  of  the  manubrium  and 
the  left  sternoclavicular  joint  were  resected  with  the  giant  rongeur  forceps 
of  Esmarch,  care  being  taken  to  avoid  disturbing  the  fragments  of  the 
eroded  clavicle.  The  thymus  gland  and  the  left  innominate  vein  were  drawn 
upward  and  to  the  right  with  a  retractor. 

The  trachea  in  the  thorax,  as  well  as  in  the  neck,  was  displaced  to  the 
right  by  the  pressure  of  the  aneurism.  The  left  carotid,  deeply  situated  and 
occupying  the  midline  in  the  chest,  was  gently  occluded  with  a  broad  tape 
ligature.  This  artery  was  thought  at  first  to  be  the  left  subclavian  inasmuch 
as,  according  to  the  erroneous  testimony  of  an  onlooker,  its  occlusion  did 
not  affect  the  pulse  in  the  left  temporal  artery,  and  lessened  the  force  of 
the  pulsation  in  the  aneurism.  To  obtain  access  to  the  left  subclavian  artery 
the  cartilage  of  the  left  first  rib  and  the  adjoining  margin  of  the  sternum 
were  cut  away.  The  arch,  the  aortic  isthmus  and  descending  aorta,  and  the 
left  auricle  of  the  heart  were  palpated  with  the  finger  of  the  operator  before 
the  left  subclavian,  lying  close  to  the  vertebral  column,  was  identified. 
With  the  aid  of  four  long,  narrow  dissectors,  two  of  which  were  manipulated 
by  the  operator  and  two  by  Dr.  Mont  Reid,  the  vessel  was  clearly  exposed 
at  its  origin  from  the  aorta  and  for  several  centimeters  distal  to  this  point. 
As  it  was  evident  that  none  of  the  various  aneurism  needles  was  suitable 
for  the  passage  of  a  ligature  at  this  depth,  a  narrow  blunt  dissector,  slightly 
curved  and  pierced  at  its  tip,  was  armed  with  fine  silk  and  passed  under  the 
artery.  By  means  of  this  thread  and  then  another,  narrow  linen  tapes  were 
drawn  under  the  subclavian ;  both  of  these  were  tied,  the  second  distal  and 
close  to  the  first,  with  force  only  sufficient  to  close  completely  the  artery's 
lumen.  The  aneurism  became  very  tense  and  hard  immediately  after  the 
ligation,  but  was  pulseless. 

The  patient's  condition,  bad  on  admission  and  particularly  so  just  before 
operation,  caused  us  some  anxiety.  Traction  within  the  thorax  on  the 
branches  of  the  aortic  arch  or  on  the  pulmonary  artery  affects  unfavorably 
and  eventually  disastrously  the  action  of  the  heart.  The  pulse,  about  120 
at  the  beginning,  was  140  +  and  quite  weak  at  the  termination  of  the  opera- 
tion. The  wound  was  completely  and  accurately  closed  with  interrupted 
sutures  of  fine  silk.  A  great  dead  space  in  the  mediastinum  was,  naturally, 
unavoidable. 

Healing  per  primam. 

November  9,  1918. — The  patient  has  been  examined  frequently  since  his 
discharge  from  the  hospital.  He  can  make  slight  movements  with  the  left 
fingers,  otherwise  there  has  been  no  appreciable  return  of  power  or  sensation 
in  the  paralyzed  arm.  There  has  been  no  pulsation  in  the  aneurism  since 
the  operation.  The  mass  has  steadily  but  slowly  been  absorbed. 


490  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

Throughout  the  year  following  the  operation  the  pulseless  tumor  slowly 
but  steadily  diminished  in  size.  Then  for  a  year  the  patient,  living  out  of 
town,  was  lost  sight  of.  Exactly  two  years  after  the  first  operation  he 
returned,  at  our  solicitation,  to  the  hospital.  Now  for  the  first  time 
since  the  operation  a  vers-  faint  pulsation  was  discernible.  The  tumor 
(Plate  XLVI,  1)  measured  in  its  transverse  (frontal)  diameter  precisely 
the  same  as  when  last  seen  a  year  before ;  the  antero-posterior  measurement 
(sagittal),  however,  gave  an  increase  of  about  4  cm.  Sensation  of  the  left 
shoulder,  arm,  forearm,  and  hand  was  quite  normal  except  for  slight  impair- 
ment to  touch  and  pin-pricks  at  the  finger-tips  and  over  the  palm  of  the 
hand.  Power  had  returned  to  the  deltoid,  supraspinatus,  pectoralis  major, 
and  rhomboid  muscles,  and  in  slight  degree  to  the  biceps  and  triceps.  From 
the  atrophied  infraspinatus  there  was  no  response.  The  patient  was  unable 
to  pronate  or  supinate  the  forearm  but  he  could  slightly  flex  and  faintly 
extend  the  wrist.  For  the  interossei  and  lumbricales  no  improvement  was 
observable. 

I  decided  that  the  aneurism  should  be  excised,  and  on  April  20,  1920, 
operated  as  follows : 

The  skin  over  the  tumor  and  a  wide  area  about  it  were  protected  with 
Chinese  silk  dipped  in  celloidin.  The  incision,  made  through  the  tightly 
adherent  silk,  ran  with  the  clavicle  in  its  central  part,  curving  up  into  the 
neck  at  its  inner  end,  and  down  along  the  cephalic  vein  at  its  outer.  Super- 
imposed on  and  not  attached  to  the  greatly  broadened  and  thickened  clavicle 
was  a  sharply  convex  bow  of  bone  about  9  cm.  long  and  6  mm.  thick.  This 
bow,  recognizable  in  the  photograph  (Plate  XLV,  2),  was  cut  away  and 
the  clavicle  bitten  through  with  a  heavy  rongueur  forceps  at  two  points  as 
close  to  the  aneurism  as  possible.  The  cephalic  vein  was  divided,  and  the 
axillary  artery — pulseless,  tape-like,*  reduced  in  size,  apparently  not  quite 
empty — was  ligated  about  at  the  junction  of  its  first  and  second  portions, 
through  a  split  made  in  the  pectoralis  minor  muscle ;  the  aneurismal  sac 
and  the  resected  rib  were  excised  in  one  piece.  The  aneurism  was  matted 
to  the  surrounding  parts  by  dense  connective  tissue,  and  hence  had  to  be 
carved  out  rather  than  enucleated.  The  identification  and  freeing  of  the 
roots  of  the  brachial  plexus,  which  were  in  places  embedded  in  the  wall  of 
the  sac,  consumed  much  time.  The  operation  was  conducted  in  a  bloodless 
manner  until  nothing  remained  to  be  done  except  to  divide  the  narrow  neck 
of  the  sac.  The  tissues  of  this  neck  proved  to  be  thin  and  friable,  and  the 
patient  lost  a  few  cubic  centimetres  of  blood  through  a  little  tear,  which 
was  readily  repaired  with  three  stitches  of  fine  silk.   The  wound  was  closed 

*  I  have  several  times  made  the  observation,  both  on  the  human  subject  and 
animals,  that  a  stretch  of  artery  destined  to  become  obliterated  may  be  partially 
or  totally  collapsed  beyond  the  point  of  occlusion  and  nearly  to  the  first  distal 
branches  although  the  blood  pressure  in  the  vessel  peripheral  to  these  branches  may 
be  approximately  normal  (vid.  Jour  Exp.  Med.,  1916,  xxiv,  276).  Hence  I  have 
questioned  the  validity  of  the  universally  accepted  view  that  the  conversion  of  the 
artery  into  a  fibrous  cord  is  due  primarily  to  the  thickening  of  the  intima.  May  not 
the  lowering  of  the  blood  pressure  in  the  discarded,  pocketed  segment  be  the 
primary  factor? 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  491 

without  drainage.  I  am  greatly  indebted  to  Dr.  Heuer  and  Dr.  Reid  for 
their  skilful  and  highly  competent  assistance  which  enabled  me  without 
fatigue  to  conduct  the  operation  to  a  satisfactory  conclusion.  The  excised 
aneurism  was  carefully  examined  by  Dr.  MacCallum,  Dr.  Reid,  Dr.  Heuer 
and  myself  and  the  decision  reached  that  no  portion  of  the  artery  had  been 
excised. 

At  the  first  dressing,  made  on  the  10th  day  after  operation,  it  was  noted 
that  a  little  fluid  had  accumulated  in  the  outer  part  of  the  wound.  This 
was  evacuated  by  puncture  with  a  wooden  toothpick  wrapped  with  a  few 
fibres  of  cotton  dipped  in  pure  carbolic  acid.  Closure  of  the  puncture  was 
prevented  by  the  reapplication  of  the  acid  in  the  same  manner  on  two  alter- 
nate days.  The  introduction  of  a  drain  of  any  kind  we  scrupulously  avoid. 
The  word  "  drainage-tube  "  is  in  disfavor  in  our  clinic.  Should  a  wound 
become  infected,  tubes  would  be  properly  introduced  for  the  purpose  of  dis- 
infection, but  not  for  drainage. 

Noteworthy  is  the  fact  that  the  patient's  hand,  which  prior  to  and  ever 
since  the  first  operation  had  been  markedly  cold,  became  strikingly  warm 
about  six  hours  after  the  second  operation.  It  is  improbable  that  the  ligation 
of  the  cephalic  vein  was  in  any  part  responsible  for  this  indubitable  im- 
provement in  the  circulation.  The  elevation  of  the  temperature  of  the  hand 
and  forearm  must,  I  believe,  be  attributable  solely  to  vasodilatation  incident 
to  the  ligations  and  severings  of  the  subclavian  and  axillary  arteries 
(Leriche).22 

Today  (June  16,  1920),  the  57th  since  the  operation,  the  left  hand  and 
forearm  are  still  warm — quite  as  warm  as  the  right.  There  are  a  few  well- 
defined,  cooler  areas,  one  of  them  to  the  outer  side  of  and  below  the  olecranon 
process  of  the  ulna. 

Analysis  of  the  Results  of  Ligation  of  the  First  Portion  of  the 
Left  Subclavian  Artery 

Six  of  the  21  cases  (28.5  per  cent)  died;  only  two  of  these  (Rodgers  and 
Marchesano)  were  operated  upon  in  the  days  before  Listerism;  in  three 
(Bardenheuer,  Kammerer,  Duval),  antiseptic  precautions  were  observed; 
the  remaining  fatality  (Lane)  occurred  in  1883.  The  wound  of  the  first 
operation  in  Lane's  case  was  closed  and  is  believed  to  have  healed  per 
primam;  the  haemorrhage,  noted  two  weeks  after  the  first  operation,  may 
have  been  due  either  to  the  fineness  of  the  silk  ligature  or  to  infection  or 
to  both ;  infection  must  have  been  the  chief  cause  of  the  haemorrhage  after 
the  second  operation.  Bardenheuer's  patient  died  18  hours  after  a  difficult, 
very  extensive,  and  presumably  bloody  operation  for  carcinoma ;  Kammerer's 
lived  one  month,  and  died  of  secondary  haemorrhage  due  to  faulty  ligature- 
material  (catgut) ;  in  Duval's  case  the  cause  assigned  for  the  sudden  death 
a  few  hours  after  the  operation  was  speculative.  Thus,  infection  was  respon- 
sible for  three  of  the  six  fatalities,  and  a  catgut  ligature  for  a  fourth.   All  of 


492  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

the  10  cases  operated  upon  in  the  last  decade  recovered.  The  21  ligations 
of  the  first  portion  of  the  left  subclavian  were  all  except  one  (Bardenheuer) 
for  aneurism.  Of  the  recovered  cases  the  aneurism  was  spontaneous  in  six, 
and  of  traumatic  origin  in  nine.  Of  the  spontaneous  aneurisms  Stonham's 
(IX)  is  the  only  one  not  pronounced  cured  by  the  simple  ligation  of  the 
subclavian.*  As  the  artery  in  this  case  coursed  high  in  the  neck  and  the 
aneurism  was  apparently  at  the  highest  point  of  the  subclavian's  arch,  and 
as,  furthermore,  the  radial  pulse  reappeared  24  hours  after  the  ligation  of 
the  subclavian,  it  would  seem  that  there  must  have  been  a  well  established 
collateral  circulation  before  the  first  operation.  May  not  a  cervical  rib  have 
been  the  primary  cause  of  this  aneurism?  The  effect  of  merely  tying  the 
subclavian  artery  was  tested  in  five  (Browne,  Rubritius,  White,  Ballance, 
Halsted)  of  the  nine  traumatic  cases.  If  my  case  (XXI)  had  been  observed 
for  a  period  less  than  the  two  years  we  should  have  believed  that  the  ligation 
alone  had  effected  a  cure  in  every  instance.  In  Browne's  case,  to  be  sure, 
the  axillary  haematoma  was  evacuated,  but  as  no  bleeding  ensued  it  may 
be  classed  in  this  group  of  cures  by  simple  ligation.  In  three  (Jungst, 
Delbet,  Wieting)  of  the  remaining  four  cases  of  this  traumatic  group  the 
blood  sac  was  opened,  evacuated,  and  stuffed  with  gauze.  The  haemorrhage 
was  profuse  on  opening  the  sac  in  all  the  three  cases,  and  in  two  of  them 
(Delbet,  Wieting)  the  tight  stuffing  was  for  the  purpose  of  controlling  it. 
In  Jiingst's  case  a  ligature  was  placed  on  each  side  of  the  slit  in  the  artery 
made  by  the  bullet,  and  in  Delbet's  the  subclavian  was  ligated  in  its  third 
portion  also,  in  order  to  control  the  "  formidable  haemorrhage "  which 
occurred  on  opening  the  sac.  In  the  remaining  one  of  the  nine  traumatic 
cases  (Xeff)  the  ligation  of  the  subclavian  was  made  for  the  control  of 
haemorrhage  resulting  from  a  tear  inflicted  by  the  operator  in  the  course 
of  a  dissection  of  the  neck  for  the  removal  of  enlarged  lymphatic  glands. 
For  the  remarkable  operative  and  postoperative  complications  in  this  case 
the  reader  is  referred  to  the  abstract  (XIII). 

Thus  the  aneurism  was  cured  by  the  simple  ligation  of  the  subclavian, 
whether  proximal  or  distal  to  the  branches  of  the  first  portion,  in  all  the 
spontaneous  aneurisms  but  one  (Stonham),  and  in  all  but  one  (Halsted) 
of  the  traumatic  variety.  By  reference  to  the  diagrams  (Figs,  53-56)  we 
note  at  a  glance  that  the  ligature  of  the  first  portion  was  distal  to  the 
branches  of  this  portion  of  the  artery  in  eight  instances  (Rodsrers,  Mar- 
chesano,  Schumpert,  Browne,  Xewbolt,  Wieting,  Hamann,  White)  and 
proximal   to   them   in   six    (Bardenheuer,   Kammerer,   Jungst,    Rubritius, 

*  The  case  of  Schumpert  (VI),  however,  was  observed  only  for  nine  weeks,  and 
.of  Newbolt  for  three  months. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTEEY  493 


Aneurism 


Wound  made 
by  chisel 


I.  Mavchesano 


Presumably  plugged  by  clot 


Is  op., Artery  severed 
by  ligature 


JL.arge  carcinoma 
involving  vessels 


IV.  Bardenheuer 


Aneurism 


Wk    Vl.Schumpert 


Fig.  53. 


494  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 


Fig.  54. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  495 


Gamp*   left   in  wound  — ►      1   op. 


ng  m  artery 


left  in  wound 


Xffl.Neff 


Rubbertube,  1*op. 

XlV.Rubritius 


Aneurism 


Gunshot  wound 
Aneurism 


XV.  Newbolt 


XVT.Wieting 


XVIl.Gaudiani 


XVIII.  Hamann 


Fig.  55. 


496 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 


Gaudiani,  Ballance  *).  In  seven  of  the  cases  (Lane,  Halsted,  Stonham, 
Delbet,  Duval,  Neff,f  Halsted)  the  subclavian  was  ligated  on  both  sides  of 
the  origins  of  its  branches,  and  in  two  of  these  (Halsted,  Halsted)  the 
aneurism  was  excised. 


Gunshot  wound 
Aneurism 


XlX.White 


Aneurism 


Huge  aneurism: 
excised     / 


Exposure  from  the  bacK 
Ugature  removed. 


Fio.  56. 

*  We  have  placed  the  ligature  of  Ballance  proximal  to  all  the  branches  except  the 
vertebral,  although  its  precise  location  is  doubtful.  Ballance  states  that  he  tied 
the  artery  behind  the  vertebral  vein.  This  vein,  irregular  in  origin,  is  usually  internal 
and  anterior  (Henle)  to  the  artery  in  this  part  of  its  course. 

t  In  Neff's  patient  the  thyroid  axis  and  the  vertebral  and  internal  mammary 
arteries  were  also  tied.  The  exact  position  of  the  hole  torn  in  the  subclavian  in  this 
case  was  not  determined  and  consequently  may  be  erroneously  indicated  in  our 
diagram. 


PLATE  XLVII 


The  excised  aneurism,  bisected  (Case  No.  XXI).  The  sac  is  filled  with  hyalin  and  com- 
pressed, laminated  old  clot,  canalized  at  the  periphery  by  the   bloodstream. 

In  the  dark,  central  areas  the  imbedded  clots  are  younger  and  studded  with  cavities 
containing  fluid  blood.  The  specimen  (actual  size)  is  probably  unique. 


PLATE   XLMII 


Purmann'e  no  168         ibe  ich  zu  Halbei- 

ne  Frau.  Anna  Peierin.  eewesene  Kretschmerin  iu  Langen- 

1S.  Jahr  alt.  mit  einem  sehr  grossen  Anevrismate  de*  line-ken 

Amies  in  die  Cur  bekommen.  damit  die  sich  sehon  uber.  3.  Jahr 

:nd    Form    ceigel  :  mmende   Figur." 

Punnann.  Chirurgia  curiosa.  ed.  1716. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  497 

In  no  case,  Stonham's  excepted,  was  there  restoration  of  the  radial  pulse 
after  operation.  In  Stonham's  patient  it  was  equal  on  the  two  sides  before 
operation  and  reappeared  2-4  hours  after  the  ligation  of  the  subclavian.  The 
anastomotic  circulation  was  presumably  well  established  before  the  opera- 
tion, for  the  reason,  as  stated  above,  that  the  presence  of  a  cervical  rib  may 
be  assumed. 

Perusal  of  the  original  accounts  of  the  cases  of  gangrene  following  liga- 
tion of  the  subclavian  artery  reveals  the  fact  that  in  each  instance  there  was 
a  serious  complication — thrombosis,  arterio-venous  fistula,  ligation  of  the 
axillary  artery,  etc.  I  have  failed  to  obtain  any  evidence  that  gangrene  has 
been  caused  by  the  uncomplicated  ligation  or  ligations  of  either  subclavian 
artery. 

In  a  paper  by  Bean '  based  upon  129  dissections  by  students  of  the  sub- 
clavian and  its  branches  recorded  upon  Bardeen's  charts  we  find  summarized 
the  views  of  Quain,  Testut,  Gray,  Henle,  Tiedemann,  Spalteholtz  and  Toldt, 
Sappey,  and  himself  as  to  the  normal  origin  of  the  branches  of  this  artery 
on  both  sides  of  the  body  (vid.  Fig.  57).  The  conclusions  arrived  at  by 
Bean  from  his  study  of  Bardeen's  charts  are  as  follows: 

"  I.  The  branches  of  the  subclavian  artery  differ  in  their  origin  on  the 
two  sides  of  the  body 

"  (a)  There  is  a  tendency  in  the  branches  of  the  subclavian  artery  to 
bunch  themselves  in  their  origin  on  the  left  side,  whereas  on  the  right  side 
there  is  a  tendency  in  each  branch  to  arise  directly  from  the  subclavian 
artery. 

"(b)  The  thyroid  axis,  dividing  into  the  suprascapular,  transverse  cer- 
vical, and  inferior  thyroid  arteries,  is  not  normal,  except  on  the  left  side. 

"(c)  The  transverse  cervical  artery  and  the  costocervical  trunk  arise 
from  the  second  part  of  the  subclavian  artery  more  frequently  on  the  right 
side  than  on  the  left  side. 

"(d)  The  superficial  cervical  artery  is  of  infrequent  occurrence,  and  is 
found  more  often  on  the  right  side. 

"(e)  The  transverse  cervical  artery  terminates  by  dividing  into  ascend- 
ing and  descending  rami,  the  latter  being  commonly  called  the  posterior 
6capular  artery.  The  former  divides  underneath  the  trapezius  muscle  and 
supplies  the  upper  and  middle  part  of  the  back. 

"  II.  There  are  five  important,  and  not  infrequent,  anomalies  to  which 
the  attention  is  directed : 

"  (a)  The  origin  of  the  right  subclavian  artery  from  the  descending  part 
of  the  aorta.  This  occurs  4-6-8  times  in  1000  cases  (0.5£  to  1#  of  all 
persons). 

"  (b)  Variableness  in  the  origin  of  the  transverse  cervical  artery,  espe- 
eially  on  the  right  side. 

"  (c)   The  presence  of  a  middle  thyroid  artery  (Thyroidea  ima). 

"(d)   The   suprascapular   artery   arising  from  the   internal  mammary 
artery. 
'33 


498  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

"(e)  The  lateral  thoracic  artery  arising  from  the  internal  mammary 
artery. 

"  III.  Eighty  per  cent  of  the  dissections  were  made  in  negro  subjects, 
a  large  number  of  whom  may  have  been  mulattoes  or  mixed  bloods.  That 
hybrids  tend  toward  variation  is  a  recognized  biological  law.  This  may 
explain  the  unusually  large  number  of  abnormalities  encountered. 

"  IV.  Twenty-three  infants  were  dissected  and  many  of  these  show  irregu- 
larities, particularly  in  the  distribution  of  the  suprascapular  artery,  which 
is  frequently  deficient,  its  place  being  taken  by  the  dorsal  scapular  artery. 

"  V.  The  branches  of  the  subclavian  artery  may  be  more  numerous  in 
adults  than  in  infants.  The  branches  rise  from  all  parts  of  the  artery  in 
adults,  whereas  in  infants  the  branches  frequentlv  rise  in  a  bunch  from 
Part  I." 

In  choosing  a  diagram  to  represent  the  norm  for  the  left  side  I  have 
accepted  the  representations  of  Quain,  Gray,  Testut,  and  Bean.  According 
to  Bean,  our  diagram  depicts  correctly  the  norm  for  the  left  side — the  side 
which  at  present  concerns  us — but  not  for  the  right  side.  Bean  states  that 
the  arrangement  shown  in  the  diagram  which  I  have  adopted  as  typical 
was  found  by  him  in  55  per  cent  of  the  students'  dissections  of  the  left 
subclavian.  For  the  right  side  the  majority  of  anatomists  give  the  origin 
of  the  arteria  transversa  colli  to  the  third  or  second  portion  of  the  vessel 
(vid.  Fig.  57). 

The  Treatment  of  Axeurisms  of  the  Subclavian  Artery 

The  six  patients  upon  whom  I  have  operated  for  aneurism  of  the  sub- 
clavian artery  recovered  ideally  without  gangrene  or  added  loss  of  function ; 
the  wounds,  all  closed  without  drain,  healed  per  primam,  and  in  all  the 
aneurism  was  cured,  but  I  am  sure  that  in  several  instances  the  operative 
measures  were  not  quite  those  I  should  under  like  circumstances  practise 
today.  For  example,  I  should  not  again,  as  in  my  first  case  (V),  excise  the 
aneurism  in  an  old  man  unless  a  proximal  ligature  had  failed  to  cure  it : 
and  I  believe  that  the  excision  of  the  aneurism  in  Case  Xo.  XXI  should  have 
been  undertaken  much  earlier  in  order  to  liberate  more  promptly  the  matted 
nerves. 

We  can  forecast  with  greater  confidence  than  for  the  subclavian  certain 
generalizations  in  regard  to  the  treatment  of  aneurisms  of  the  extremities 
situated  so  low  that  an  elastic  band  or  tourniquet  may  be  satisfactorily 
applied  above  them.  In  such  cases  the  sac  should  be  opened  and  excised 
and  a  suture — lateral  or  end-to-end — be  made,  when  feasible.  The  openings 
in  the  sac  of  the  afferent  and  efferent  ends  of  the  artery  may  be  only  a  few 
lines  apart.  Within  the  past  18  months  Dr.  Mont  Reid  (resident  surgeon) 
of  our  staff  at  The  Johns  Hopkins  Hospital  has  once  made  a  lateral  and 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  499 

ACS ACA/^ 


A. 


Fig.  57. — Branches  of  the  subclavian  artery  according  to  different 
authors.  A,  according  to  Quain,  Testut  and  Gray;  B,  according  to 
Henle;  C,  according  to  Tiedemann;  D,  according  to  Spalteholz  and 
Toldt  (B.  N.  A.);  E,  according  to  Gegenbauer;  F,  according  to 
Sappey. 

The  lettering  on  all  the  figures  is  alike  and  as  follows:  I,  II  and 
HI,  the  three  parts  of  the  subclavian  artery;  A.  V.,  arteria  verte- 
bralis;  A.M.  I.,  arteria  mammaria  interna;  T.T.C.,  truncus  thyreo- 
cervicalis;  A.T.I.,  arteria  thyroidea  inferior;  A.T.S.,  arteria  trans- 
versa scapula;  A.T.C.,  arteria  transversa  colli;  R.A.T.C.,  ramus 
ascendens  transversa  colli  R.D.T.C,  ramus  descendens  transversa 
colli;  A.C.S.,  arteria  cervicalis  superficialis ;  A.C.A.,  arteria  cervi- 
calis  ascendens;  T.C.C.,  truncus  costocervicalis;  A.I. S.,  arteria 
intercostalis  suprema;  A.C.P.,  arteria  cervicalis  profunda;  C.T., 
common  trunk. 


500  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

twice  an  end-to-end  suture  in  cases  of  aneurism  of  the  popliteal  artery.  In 
each  instance  the  pulse  in  the  tibial  arteries  was  immediately  and  perma- 
nently restored.  If  the  artery  has  been  ligated  the  operator  must  carefully 
observe  the  state  of  the  circulation  in  the  foot,  making  use  of  one  or  more 
of  the  several  tests  at  his  disposal.  If  there  is  reason  to  fear  gangrene,  he 
should  note  the  effect  of  occlusion  (temporary  or  permanent)  of  the  cor- 
responding vein.  If  gangrene  still  threatens,  the  interpolation  of  a  piece  of 
vein  between  the  arterial  ends  is  indicated  and  should  be  undertaken  pro- 
vided the  surgeon  has  made  himself  proficient  in  the  art  of  suturing  blood 
vessels.  It  is  clearly  the  duty  of  every  surgeon  to  practise  on  animals  the 
end-to-end  suture  of  arteries  until  he  has  become  master  'of  the  technique. 
To  consider  the  proper  procedures  for  surgeons  of  diverse  degrees  of  quali- 
fication would  involve  us  in  a  discussion  too  prolonged. 

Agreed  as  to  what  the  treatment  should  be  of  aneurisms  of  the  extremi- 
ties whose  blood  supply  can  usually  be  controlled,  we  may  advance  to  the 
consideration  of  the  extent  to  which  these  ideal  procedures  may  be  appli- 
cable to  aneurisms  in  or  above  the  groin  and  axilla — above,  in  other  words, 
the  domain  of  the  tourniquet.  It  is  clear,  I  think,  that  aneurisms  of  the  neck 
and  groin  should  not  be  incised  until  their  arterial  supply  on  all  sides  has 
been  temporarily  shut  off.  When  a  ligature  can  be  applied  between  the 
proximal  pole  of  the  aneurism  and  the  branches  of  the  first  and  second  por- 
tions of  the  subclavian  artery  and  another  beyond  and  close  to  the  distal 
pole,  the  sac  may,  if  there  are  indications  for  doing  so,  be  safely  opened, 
for  in  only  a  small  percentage  of  the  cases  would  a  branch  (the  arteria 
transversalis  colli)  be  a  possible  source  of  annoyance.  If  the  aneurism  is  of 
one  of  the  first  two  portions  of  the  subclavian  and  the  ligature  has  been 
applied  proximal  to  the  grouped  branches  it  would  always  be  troublesome 
and  sometimes  impossible  to  shut  off  its  blood  supply  completely.  It  is  for- 
tunate, therefore,  that  such  a  large  percentage  of  the  aneurisms  of  the  left 
subclavian  have  been  cured  merely  by  ligation  of  its  first  portion.  An  indi- 
cation for  immediate  opening  of  the  sac  might  be  the  paralysis  due  to  pres- 
sure. In  the  majority  of  cases  I  should  be  inclined  to  test  the  effect  of 
proximal,  or  proximal  and  distal,  ligation.  Should  pulsation  persist  after 
the  double  (proximal  and  distal)  ligation  of  the  subclavian  I  should,  when 
the  wounds  from  the  first  operation  were  firmly  healed,  or  sometime  there- 
after, excise  the  aneurism.  Certainly  one  should  not  cut  into  a  pulsating 
aneurism,  and  to  search  for  and  ligate  all  the  branches  of  the  first  portion 
might  be  an  undertaking  more  formidable  than  the  excision  of  the  sac; 
it  might  indeed  be  quite  impossible  to  secure  these  tributaries  without  first 
dislodging  the  tumor.  I  should  even  hesitate  to  open  a  non-pulsating  aneu- 
rism which  had  shown  no  tendency  to  decrease  in  size.   If  for  any  reason 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  501 

a  surgeon  has  decided  to  slice  into  an  aneurism  of  the  subclavian,  niy  advice 
to  him  would  be  to  free  first  by  dissection  as  much  of  the  tumor  as  possible 
and  then  split  it  -widely  to  the  deepest  parts.  An  operator  searching  for  a 
bleeding  point  in  a  pool  of  blood,  and  particularly  so  when  embarrassed  in 
his  movements  by  the  adherent  walls  of  an  aneurism  within  which  he  is 
working  so  disadvantageously,  presents  a  distressing  spectacle.  I  would 
rather  devote  an  additional  hour  or  more  to  an  operation  than  be  caught 
for  a  few  moments  in  such  a  predicament. 

Common    errors    in    the    treatment    of    aneurisms    are    the    following: 

(1)  opening  the  sac  or  pulsating  haematoma  without  first  making  a  tem- 
porary occlusion  of  all  the  possible  sources  of  haemorrhage;  (2)  permanent 
ligation  of  a  great  arterial  trunk  as  a  precautionary  measure  in  the  search 
for  a  distal  bleeding  point;  (3)  ligation  of  a  trunk  too  far  from  the  aneu- 
rism; (4)  stuffing  the  wound  with  gauze  to  arrest  haemorrhage;  (5)  drain- 
age; (6)  the  employment  of  catgut  for  the  ligature,  or  of  silk  that  is  too 
fine ;  ( 7 )  ligation  of  the  artery  proximal  to  an  arterio-venous  aneurism  or 
fistula. 

May  Gangrene  be  Prevented  by  Ligation  of  the  Vein  Corresponding 
to  the  Occluded  Artery? 

In  1906  von  Oppel  **  and  Korotkow  made  observations  in  the  course  of 
three  operations  in  one  day  for  the  cure  of  arterio-venous  fistula  which  are 
of  fundamental  importance  in  their  bearing  on  the  question  of  ligating  the 
vein  corresponding  to  the  artery  with  the  idea  of  preventing  gangrene. 
Yon  Oppel's  account  of  this  experiment  on  the  human  subject,  well  worth 
preserving  in  the  English  language,  is  as  follows : 

"Male,  aet.  32.  Wounded  in  the  left  shoulder  bv  a  rifle  ball.  Entered 
hospital  in  St.  Petersburg,  April  26.  1905. 

"Diagnosis. — Aneurysma  arterio-venosum  axillare;  collateral  arterial 
routes  fairly  developed. 

"  May  5,  1905.  The  first  operation  began  at  11  o'clock  in  the  morning 
and  ended  at  11.30.  The  incision  was  begun  a  finger-breadth  above  the 
border  of  the  pectoralis  major  muscle  and  carried  7  cm.  downwards.  The 
N.  cutaneus  medius  was  drawn  outwards,  the  vein  exposed.  Exactly  in  the 
neighborhood  of  the  pulsating  tumor  two  brachial  veins  emptied  into  the 
axillary  vein.  The  latter  was  varicose  immediately  above  the  site  of  the 
junction.  A  rather  thick  collateral  branch  was  given  off  from  the  inner  of 
the  two  brachial  veins.  Wishing  to  abbreviate  the  intervention  as  much  as 
possible  I  decided   (1)   to  ligate  the  axillary  artery  above  the  aneurism; 

(2)  to  ligate  the  external  brachial  vein  in  order  to  retard  the  flow  of  the 
venous  blood.  I  believed  that  the  communication  with  the  aneurismal  sac 
was  located  in  the  varicose  portion  of  the  dilated  vein.  Without  laying  bare 
the  aneurismal  sac.  I  pushed  the  X.  medianus  and  the  axillary  vein  outwards 
and  divided  the  axillary  arterv  between  ligatures. 


502  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

"  The  operation  was  carried  on  without  the  application  of  an  elastic  ban- 
dage above  the  aneurism,  hence  Korotkow  was  able,  immediately  after  the 
division  of  the  artery,  to  measure  the  blood  pressure  in  the  fingers.  To  our 
surprise  this  was  0,  and  the  extremity  became  pale.  As  I  was  sure  from 
previous  examinations  that  the  collateral  routes  were  sufficient  and  attrib- 
uted the  result  of  the  measurement  of  the  blood  pressure  to  some  accidental 
cause,  I  completely  closed  the  wound  and  applied  a  dressing. 

"  However,  although  the  extremity  became  warmer,  the  blood  pressure 
did  not  rise.  At  1.30  in  the  afternoon  the  arm  was  deathly  pale,  the  blood 
pressure  0.  On  the  volar  surface  of  the  thenar  eminence  there  developed  a 
bluish  dark  red  oval  spot.  Immediately  on  regaining  consciousness  the 
patient  began  to  complain  of  extraordinarily  severe  pains  in  the  arm.  The 
forearm  and  hand  were  insensitive  and  completely  paralyzed  (ischaemic 
paralysis),  the  cutaneous  veins  entirely  collapsed — in  a  word,  gangrene  of 
the  extremity  was  developing  beneath  our  eyes. 

"  This  state  of  affairs  needed  clarifying  and  the  explanation  which  Korot- 
kow gave  was  so  convincing  that  I  declared  myself  in  full  agreement  with 
him.  Korotkow  reasoned  as  follows :  Since  the  axillary  vein  above  the 
aneurism  and  the  axillary  artery  below  the  aneurism  were  not  ligated,  the 
arterial  blood  of  the  collateral  routes  was  being  carried  off  by  the  veins 
through  the  aneurismal  sac.  In  order  to  remove  this  influence  of  the  veins 
one  should  ligate  the  axillary  artery  above  the  aneurism. 

"  The  second  operation,  likewise  under  chloroform  narcosis,  was  begun, 
without  elastic  bandage,  at  3.30  in  the  afternoon,  and  finished  at  4.30 
o'clock.  The  wound  was  opened,  the  axillary  vein  exposed  above  the  aneu- 
rism and  divided  between  ligatures.  In  spite  of  this  the  blood  pressure 
remained  0.  As  the  explanation  given  above  in  regard  to  the  cause  of  the 
gangrene  appeared  to  be  irrefutable,  one  had,  in  seeking  a  reason  for  the 
lack  of  effect  of  the  ligation  of  the  axillary  vein,  to  find  it  in  the  existence 
of  some  accessory  veins  which  might  carry  away  the  blood  from  the  aneu- 
rismal sac.  Consequently,  I  began  to  search  for  accessory  veins,  whereupon 
quickly  the  evolution  was  as  follows:  Scarcely  had  I  compressed  with  the 
finger  the  space  between  the  stumps  of  the  divided  artery,  when  the  forearm 
and  hand  immediately  became  red,  and  Korotkow,  who  uninterruptedly  was 
measuring  the  blood  pressure  in  the  fingers,  observed  a  rise  in  the  blood 
pressure  to  40  mm.  I  had  hardly  removed  the  finger  when  the  blood  pressure 
went  back  to  0,  and  the  extremity  again  became  pale. 

"  Considering  these  facts,  I  began  to  dissect  the  deeper  parts  of  the 
axilla  behind  the  artery  and,  in  fact,  found  there  an  abnormally  thick 
venous  trunk.  The  size  of  this  vein  was  not  less  than  that  of  the  axillary 
vein,  which  lay  in  front  of  the  artery.  This  venous  trunk — the  V.  axillaris 
profunda — was  isolated,  and  divided  between  ligatures.  The  blood  pressure 
in  the  fingers  rose  to  40  mm. ;  the  extremity  became  red.  Wound  completely 
closed ;  aseptic  dressing. 

"  When  the  dressing  was  about  completed  I  noticed  that  the  arm  was 
again  becoming  pale.  In  putting  on  the  dressings  the  arm  had  been  held 
in  the  vertical  position.  When  lowered,  the  arm  reddened  somewhat.  The 
patient  was  put  to  bed,  and  to  the  arm,  dependent,  hot  water  bottles  were 
applied. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  503 

"  As  the  patient  came  to  himself  he  again  began  to  complain  of  severe 
pains ;  the  blood  pressure  was  falling  fast.  Although  complete  paralysis  was 
not  present,  there  were  suggestions  of  beginning  gangrene  in  the  hand  and 
forearm.  The  second  operation  had  undoubtedly  brought  about  an  improve- 
ment in  the  circulation  in  the  hand  and  forearm ;  but  the  improvement  was 
not  yet  sufficient,  and  the  danger  of  gangrene  developing  had  not  passed. 
At  7.30  in  the  evening  the  blood  pressure  in  the  fingers  again  sank  to  0. 
When  the  arm  was  held  up  a  high  degree  of  bloodlessness  ensued  immedi- 
ately; when  lowered,  it  recolored  barely  if  at  all.  Pains  as  before;  the 
ischaemic  paralysis  increased. 

"  On  account  of  the  threatening  symptoms  I  decided  to  operate  again, 
to  excise  the  aneurismal  sac.  We  attributed  the  increase  in  the  symptoms 
of  beginning  gangrene  to  the  dilatation  of  the  collateral  venous  routes, 
which  again,  through  the  efferent  arterial  trunk,  took  up  the  collateral  blood 
by  way  of  the  aneurismal  sac. 

"  Third  operation  under  chloroform  narcosis,  without  elastic  bandage. 
Begun  at  8.30  p.  m.,  ended  at  9.30  p.  m.  The  lower  half  of  the  wound  was 
opened,  the  incision  lengthened  downwards.  Starting  at  the  point  above 
the  sac  where  the  artery  and  the  veins  were  divided,  I  began  gradually  to 
dissect  out  the  sac.  The  radial  nerve,  which  was  somewhat  adherent  to  the 
sac,  was  freed.  The  sac  itself  had  invaded  the  M.  brachialis  internus. 
During  the  dissection  the  sac  was  wounded  and  a  feeble  stream  of  arterial 
blood  issued  from  it.  This  circumstance  was  the  best  evidence  that  the  blood, 
actually  streaming  back  out  of  the  efferent  arterial  trunk,  coursed  into  the 
aneurismal  sac,  to  be  carried  out  of  it  back  to  the  heart  by  the  veins.  After 
the  sac  was  excised  it  was  found  that  several  veins  led  out  from  it. 

"  Scarcely  were  the  distal  veins  *  ligated  and  the  sac  excised  when  the 
hand  and  the  lower  third  of  the  forearm  became  very  hyperaemic ;  the  blood 
pressure  in  the  fingers  rose  to  30  mm.  Hg.  The  hyperaemia  reminded  one 
exactly  of  that  which  usually  follows  the  removal  of  the  elastic  bandage ; 
it  was  sharply  circumscribed,  on  the  dorsal  surface  of  the  forearm  reaching 
to  13  cm.  above  the  radio-carpal  joint,  and  on  the  volar  surface  to  7  cm. 
above  this  joint.  In  addition,  I  would  say  that  this  hyperaemia  lasted  for 
24  hours,  f 

"  It  was  also  clear  that  if  the  third  operation  had  not  been  performed, 
it  was  exactly  this  hyperaemic  region  which  would  have  broken  down. 

"  Closure  of  the  wound.  Introduction  of  a  strip  of  gauze  into  the  lower 
angle  of  the  wound.  Aseptic  dressing. 

"At  11.30  p.  m.  the  patient  became  conscious.  Xo  trace  of  the  pains 
and  paralysis  remained.    The  pareses  which  were  present  before  the  opera- 

*  In  the  course  of  the  excision  of  the  sac  the  axillary  artery  must  have  been  ligated 
both  above  and  below  the  fistulous  communication  with  it  or,  what  amounts  to  the 
same  things  so  far  as  the  circulation  is  concerned,  the  arterial  neck  of  the  sac  must 
have  been  tied.  Thus  the  result  of  the  three  operations  was  excision  of  the  aneurism 
with  ligation  of  axillary  artery  and  vein  both  above  and  below  the  sac  and  of  other 
vessels  encountered  in  the  course  of  the  dissection.    (W.  S.  H.) 

t  May  not  the  persistence  of  the  hyperaemia  be  ascribed  to  the  arterial  sympathec- 
tomy?   (W.  S.  H.) 


504  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

tion  and  which  were  caused  by  the  adhesion  of  the  radial  nerve  to  the  aneu- 
rismal  sac  had  likewise  disappeared. 

"Uneventful  postoperative  course.  Temperature  normal.  Stitches  re- 
moved on  the  5th  day.  Healing  throughout  per  primam.  From  out  of  the 
region  of  the  tampon  a  moderate  quantity  of  clear  Lymph  issued  for  the 
first  few  days.  On  the  day  after  operation  the  arterial  pressure  in  the 
fingers  rose  to  40  mm.  Over  the  gangrenous  spot  on  the  thenar  eminence 
the  necrotic,  superficial  skin  came  away.  The  patient  was  discharged  entirely 
cured  and  in  good  health." 

If  the  sac  had  been  excised  at  the  primary  operation  of  von  Oppel  the 
result  would  have  taught  us  nothing — an  opportunity  would  have  been  lost. 
I  wish  to  emphasize  this  fact  in  the  hope  that  surgeons  may  bear  always 
in  mind  the  opportunities  which  they  have  daily  at  the  operating  table  to 
strive  for  results  which  may  be  contributory  to  the  advancement  of  their 
science. 

The  operating  room  is  a  laboratory  for  the  surgeon. 

Learning  by  the  ordinary  routine  experiences  of  practice  what  might 
have  been  ascertained  from  experimentation  on  animals  cost  in  the  last  war 
an  appalling  loss  of  life  and  limb. 

The  lesson  taught  by  von  Oppel  and  Korotkow  seems  to  have  been  for- 
gotten or  overlooked  even  by  the  Germans,  for  no  mention  is  made  of  it  by 
either  Sehrt  M  or  Propping/7  the  first  of  the  surgeons  of  Germany — one 
must  conclude  from  their  communications — to  discuss  in  general  terms  the 
vascular  balance  and  to  advocate  as  a  routine  procedure  the  simultaneous 
ligation  of  the  vein  and  artery : 

Sehrt.  "  The  outflow  or  better  the  sucking  up  of  the  venous  blood  may 
best  be  prevented  by  ligation  of  the  veins.  Everything  which  accelerates 
the  sucking  away  of  venous  blood  (activity  of  the  heart,  etc.)  from  an  ex- 
tremity robbed  of  its  arterial  supply  must  contribute  to  the  death  of  the 
part  deprived.  Thus  may  be  explained  cases  in  which  definite  gangrene  of  a 
segment  of  an  extremity  has  appeared  some  little  time  after  the  receipt  of 
the  injury  and  after  the  general  condition  and  especially  the  heart's  force 
had  improved.  Every  one  may  well  have  seen  such  cases.  Under  certain 
circumstances  a  severely  injured  member  may  be  carried  over  the  most 
dangerous  period  by  venous  blockage/' 

Propping.  "  One  sees,  therefore,  that  my  explanation  of  the  possible 
cause  of  gangrene  of  a  limb  after  ligation  of  an  artery  goes  farther  than 
Sehrt's.  In  place  of  the  '  sucking  away  of  the  venous  blood '  I  advance  the 
idea  of  a  disproportion  between  in-  and  out-flow — to  a  certain  extent  a  dis- 
turbance of  balance  of  these  two  factors  * — in  order  to  explain  the  insuffi- 

*  Stromeyer  in  his  Handbuch  der  Chirurgie,  1844,  p.  371,  proposes:  "  In  Fallen  wo 
varicose  Beingeschwiire  fur  die  Erhaltung  des  Gliedes  Gefahr  drohen  und  die  Opera- 
tion der  Varices  nicht  rathsam  erscheint,  glaube  ich,  dass  man  durch  Unterbindung  dcr 
arteria  cruralis  das  Gleichgewicht  in  der  Zuleitung  und  dem  erschwerten  Abflusse  des 
Blutes  loieder  herstellen  konne." 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  505 

cient  filling  of  the  capillary  bed  and  the  thereby  conditioned  derangement 
of  the  nutrition  of  the  tissues." 

At  the  Seance  of  July  4,  1917,  of  the  Societe  de  Chirurgie  Professor 
Tuffier  M  gave  his  views  on  the  subject  of  the  ligation  of  the  vein : 

"  We  all  know  that  the  three  arterial  ligations  which  most  often  expose 
patients  to  grave  dangers  of  disturbance  are  ( 1 )  those  of  the  femoral  trunk, 
(2)  those  of  the  carotid  at  its  bifurcation,  and  (3)  those  of  the  popliteal 
artery  in  the  lower  half  of  the  popliteal  space.  If  I  believe  everything  that 
I  have  seen  of  ligations  since  the  beginning  of  this  war,  it  is  that  the  occlu- 
sion of  the  popliteal  in  its  lower  half  causes  most  disasters ;  gangrene  of  the 
limb  is  very  often  a  consequence  of  it. 

"  To  lessen  the  chances  of  ischaemia  or  of  the  gangrene  following  liga- 
tures in  these  regions,  it  has  been  advised  to  have  recourse  more  often  to 
lateral  sutures  in  all  cases  where  the  nature  of  the  lesions  permitted  it,  and 
I  fully  share  this  opinion.  There  is  a  great  advantage  in  having  recourse 
to  arterial  sutures ;  they  are  less  difficult  to  place  than  one  believes. 

"  There  is  a  practice  to  which  I  desire  again  to  direct  your  attention  in 
this  connection ;  it  is  ligation  of  the  corresponding  healthy  vein  in  all  cases 
of  ligation  of  the  great  vessels  of  the  root  of  the  limbs.  This  question,  raised 
long  ago,  can  find  in  actual  occurrences  some  particularly  suggestive  statis- 
tics. There  is  first  a  fact  which  appears  well  demonstrated;  it  is  that  liga- 
tion of  the  vein  and  of  the  artery  in  the  case  of  wounds  of  the  two  vessels 
does  not  increase  the  danger  of  ischaemia.  Moreover,  the  statistics  of  the 
English  arm}',  which  Sir  George  Makins  has  communicated  to  us,  give  in 
this  connection  the  following  ratios :  Ligation  of  the  artery  alone  is  followed 
in  a  general  way  by  gangrene  in  40.2  per  cent,  whereas  simultaneous  ligation 
of  the  artery  and  of  the  vein  under  the  same  conditions  gives  24.5  per  cent; 
and  I  speak  only  of  gangrene  from  ischaemia. 

"  The  most  marked  difference  is  in  connection  with  the  popliteal ;  ligation 
of  the  artery  alone  in  24  cases  gave  favorable  results  in  58.33  per  cent,  and 
gangrene  in  41.66  per  cent.  Simultaneous  ligation  of  the  artery  and  of  the 
vein  has  given  in  28  cases  22  favorable  results  and  only  six  cases  of 
gangrene." 

The  firm  position  taken  by  such  an  authority  as  Sir  George  Makins  has 
greatly  influenced  the  surgeons  of  England  and  France,  and  his  advocacy 
of  the  procedure  made  it  almost  mandatory  in  these  countries  in  the  last 
years  of  the  war  to  occlude  the  vein  accompanying  the  ligated  artery.  The 
arguments,  summarized  in  his  most  admirable  book,  "  On  Gunshot  Injuries 
to  the  Blood- Vessels  "  "  (1919)  are  as  follows: 

"  In  preparing  a  former  contribution  to  the  surgery  of  wounded  arteries,* 
I  was  much  struck  by  the  observation  that  proximal  ligature  of  the  femoral 
artery  in  cases  of  arterio-venous  aneurysm  was  followed  in  a  large  propor- 
tion of  instances  by  gangrene  of  the  limb,  while  excision  of  the  implicated 
segments  of  both  artery  and  vein  gave  consistently  good  results.   An  expla- 

*  "  Bradshaw  Lecture,  1913." 


506  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

nation  of  this  apparent  inconsistency  will  be  found  below,  as  also  further 
considerations  which  led  me  to  conclude  that  when  an  artery  needs  to  be 
tied,  the  satellite  vein  should  be  occluded  also. 

"  It  is  to  be  regretted  that  John  Hunter  himself  did  not  write  the  paper 
describing  his  operation  of  proximal  ligature  and  the  grounds  upon  which 
he  was  led  to  undertake  it.  In  at  least  one  of  the  cases  described  in  the 
paper  by  Sir  Everard  Home,*  possibly  in  the  first  three,  both  the  femoral 
artery  and  vein  were  included  in  the  ligature ;  in  the  fourth  we  are  definitely 
told  that  the  artery  only  was  included.  From  that  period  onwards  surgical 
opinion  has  been  definitely  to  the  effect  that  the  greatest  care  should  be 
taken,  when  occluding  a  main  artery,  to  avoid  all  injury  to  the  vein.  In  fact, 
every  operation  for  the  ligature  of  an  artery  has  been  so  devised  that  the 
aneurysm  needle  is  passed  in  a  direction  away  from  the  vein  in  order  to 
minimize  the  risk  of  injury  to  that  vessel,  not  alone  to  avoid  the  technical 
inconvenience  of  immediate  haemorrhage,  but  also  with  the  definite  object 
of  preserving  the  venous  circulation  intact. 

"  Observation  of  a  large  number  of  coincident  wounds  of  large  arteries 
and  veins  has  in  no  way  endorsed  the  view  that  simultaneous  occlusion  of 
both  artery  and  vein  exercises  any  deleterious  influence  on  the  subsequent 
collateral  arterial  circulation  and  the  vitality  of  the  limb.  In  support  of 
this  statement  a  few  examples  illustrating  the  innocuous  nature  of  opera- 
tions for  the  occlusion  of  veins  in  general  may  be  first  given.  Operations 
for  the  cure  of  varicose  veins  have  demonstrated  the  ease  with  which  a  com- 
pensatory balance  is  attained  when  the  blood  is  diverted  from  the  larger 
channels.  Occlusion  of  the  internal  jugular  and  other  large  venous  trunks 
effected  in  order  to  prevent  the  diffusion  of  septic  emboli  has  not  given  rise 
to  obvious  permanent  trouble.  As  is  well  known  also,  occlusion  even  of  the 
vena  cava  by  surgical  methods  has  been  survived,  and  the  capacity  of  the 
venous  circulation  to  maintain  itself  by  compensatory  changes,  which  is 
seen  when  this  vessel  undergoes  obstruction  by  thrombosis,  is  a  familiar 
experience. 

"  In  a  very  considerable  proportion  of  gunshot  injuries  to  large  arterial 
trunks  the  neighboring  vein  is  contused  and  becomes  thrombosed,  and  this 
has  not  been  shown  to  give  rise  to  increased  risk  of  gangrene  of  the  limbs. 
Ligature  of  the  common  carotid  artery  together  with  the  internal  jugular 
vein  en  masse  has  been  performed  in  cases  of  emergency  without  increased 
risk  of  the  development  of  the  cerebral  anaemia  and  softening  so  often  a 
consequence  of  ligature  of  the  artery  alone.  Further,  where  simultaneous 
ligature  of  both  artery  and  vein  in  other  parts  of  the  body  has  been  obli- 
gatory on  account  of  wounds  of  both  vessels,  untoward  events  have  not  been 
observed. 

"  Evidence  exists,  moreover,  that  under  certain  conditions  simultaneous 
occlusion  of  both  artery  and  vein  is  a  preferable  procedure.  The  first  exam- 
ple, not  an  unmixed  or  simple  one,  may  be  sought  in  the  results  observed 
to  follow  the  application  of  a  single  proximal  ligature  to  the  artery  in  cases 
of  arterio-venous  aneurysm  or  aneurysmal  varices  of  the  femoral  vessels. 

*  "  John  Hunter's  Works.  Palmer's  edition,  vol.  iii,  p.  604." 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  507 

In  patients  so  treated  during  the  South  African  War,*  gangrene  of  the  limb 
followed  in  more  than  50  per  cent  of  the  cases.  The  frequency  of  this 
accident  finds  a  simple  explanation  if  we  consider  what  actually  results  from 
the  operation.  The  main  vessel  being  occluded  and  the  direct  arterial  pres- 
sure from  behind  being  abolished,  blood  which  has  been  carried  by  the 
arterial  collaterals  to  the  distal  portion  of  the  injured  trunk,  instead  of 
passing  to  the  peripheral  circulation,  takes  the  course  of  least  resistance 
backwards  into  the  vein  through  the  arterio-venous  communication,  and 
thus  the  limb  practically  bleeds  to  death  much  in  the  same  way  as  if  the 
distal  end  of  the  wounded  artery  opened  on  the  surface  of  the  limb.  Hence 
the  comparative  safety  of  removal  of  the  communication  en  masse  and  occlu- 
sion of  all  four  openings  by  ligature  which  has  been  confirmed  by  numerous 
operations  during  the  present  war. 

"  A  more  striking  example  is  offered  by  the  result  of  ligaturing  the  popli- 
teal vein  alone  for  the  treatment  of  senile  gangrene  of  the  foot.  W.  A.  Oppel,f 
ascribing  the  good  results  occasionally  observed  to  follow  arterio-venous 
anastomosis  for  the  cure  of  this  condition  to  control  of  the  venous  circulation 
and  consequent  rise  in  the  blood  pressure  of  the  limb,  was  led  to  substitute 
simple  occlusion  of  the  popliteal  vein  to  produce  the  same  effects.  In  six 
cases  thus  treated  the  extremities  were  seen  to  recover  not  only  their  warmth 
and  color  without  the  development  of  oedema,  but  also  a  certain  degree  of 
hyperaemia  of  the  feet  and  toes. 

"  On  these  and  other  grounds  it  must  be  admitted  that  the  balance  of  the 
collateral  circulation  is  likely  to  be  more  efficiently  maintained  if  the  vessels 
which  carry  it  on  more  nearly  correspond  in  size  and  consequent  equality  in 
the  blood  pressure  and  rate  of  flow.  The  elimination,  in  fact,  of  the  capa- 
cious main  vein  is  a  real  advantage,  since  this  for  the  time  affords  a  too 
ready  channel  of  exit  for  the  diminished  arterial  supply,  as  well  as  an  unde- 
sirable reservoir  for  stagnation. 

"  These  considerations  have  led  me  not  only  to  regard  obligatory  simul- 
taneous occlusion  of  a  main  artery  and  vein  as  a  negligible  factor  in  the 
risk  of  gangrene  of  a  limb ;  but  to  hold  further,  that  the  procedure  is  pref- 
erable whether  the  vein  be  wounded  or  not;  the  result  of  the  combined 
procedure  being  to  maintain  within  the  limb  for  a  longer  period  the  smaller 
amount  of  blood  supplied  by  the  collateral  arterial  circulation,  and  hence 
to  improve  the  conditions  necessary  for  the  preservation  of  the  vitality  of 
the  limb. | 

"  M.  van  Kend  tested  the  accuracy  of  the  above  conclusions  as  to  the  rise 
of  blood  pressure  at  the  laboratory  of  the  Ocean  Ambulance  at  La  Panne 
by  some  experiments  on  animals,  and  made  the  following  remarks  in  his 
observations  at  the  Inter-allied  Conference  of  Surgeons  held  in  Paris  in 
May,  1917: 

'In  carrying  out  a  series  of  experiments  made  with  the  object  of  determining  the 
indications  and  the  physiological  basis  for  transfusion  of  blood,  I  have  had  the  oppor- 
tunity of  measuring  the  blood  pressure  in  limbs  of  which  the  main  artery  had  been 

*  "  Surgeon-General  W.  F.  Stevenson,  Report  on  the  Surgical  Cases  noted  in  the 
South  African  War,  1899-1902." 
t"  Zentralblatt  fiir  Chirurgie,  1913,  No.  31,  p.  1241.'' 
t "  Hunterian  Oration,  Lancet,  vol.  i,  1917,  Feb.  17,  p.  249." 


508  LIGATION  OF  LEFT  SUBCLAVIAN  AETEEY 

ligatured.  The  blood  pressure  was  taken  successively  after  the  artery  alone  had  been 
tied,  and  again  when  ligature  of  the  vein  had  been  superadded.  Mv'  observations 
confirm  the  view  that  has  been  expressed  by  Sir  George  Matins:  in  fact,  plethysmo- 
graphic  tracings  demonstrate  clearly  that  a  slight  rise  in  the  blood  pressure  in  the 
limb  follows  the  application  of  a  ligature  to  a  main  vein,  after  previous  ligature  of 
the  artery. 

1  It  appears,  then,  from  the  standpoint  of  the  physiologist,  that  to  leave  the  main 
vein  viable  after  occlusion  of  the  main  artery  of  a  limb,  diminishes  what  maj*  be 
called  the  residuary  blood  pressure  maintained  by  the  collateral  circulation.  If  the 
contribution  of  the  collateral  circulation  is  allowed  to  remain  with  the  main  vein 
intact,  it  is  natural  that  the  residuary  blood  pressure  should  fall.  If  this  view  be 
adopted,  ligature  of  the  vein  as  well  as  the  artery  should  be  recommended  in  order 
to  retain  the  blood  supplied  in  longer  contact  with  the  tissues.  Thus  the  most  satis- 
factory conditions  for  the  maintenance  of  the  nutrition  of  the  organs  are  provided, 
because  the  obstacle  to  the  return  circulation  provided  by  ligature  of  the  vein  retains 
the  blood  for  a  longer  period  in  the  member.' 

"  After  discussion  of  the  question  at  the  meeting,  the  following  conclu- 
sion was  adopted : 

■  Contrary  to  what  has  until  now  been  believed,  simultaneous  ligature  of  both  artery 
and  vein  when  both  vessels  have  been  wounded  does  not  give  rise  to  increased 
risks  of  gangrene;  in  fact  it  diminishes  them.  Facts  tend  to  prove,  even  when  the 
wound  is  limited  to  the  artery,  that  simultaneous  occlusion  of  the  unwounded  vein  is 
to  be  recommended."  * 

"  Major  Hamilton  Drummond  has  kindly  furnished  me  with  a  note  re- 
garding some  investigations  which  he  made  on  this  subject  in  the  case  of 
the  visceral  vessels.  Loops  of  the  small  intestine  of  the  cat,  and  of  the  colon 
of  the  Belgian  hare,  were  made  use  of.  After  a  careful  study  made  by 
means  of  barium  injections  and  X-ray  photographs  to  determine  the  num- 
ber of  vessels  which  should  be  ligatured  in  order  to  avoid  error  from  leav- 
ing too  free  an  anastomotic  supply,  the  following  experiment  was  made  six 
times  on  cats'  intestine : 

'A  loop  of  ileum  towards  the  caecal  end  was  drawn  out  of  the  abdomen,  and  the 
arteries  and  veins  supplying  about  five  inches  of  the  gut  were  ligatured,  cutting  off 
the  total  macroscopical  blood  supply  to  that  portion.  The  loop  was  returned  into  the 
abdomen,  and  a  second  loop  about  six  inches  higher  was  delivered  and  devascularized 
by  ligature  of  the  artery  alone. 

'  Of  six  experiments  performed  upon  the  cat.  in  three  a  definite  ring  of  gangrene 
developed  in  the  middle  of  the  segment  of  bowel  which  had  been  deprived  of  its 
arterial  supply  alone,  while  the  segment  treated  by  simultaneous  ligature  of  artery  and 
vein  showed  little  or  no  change.  In  one  case  where  the  animal  was  killed  while  still 
looking  in  good  health,  twenty-four  hours  after  ligature  of  the  vessels,  the  segment 
treated  by  ligature  of  the  arteries  only  showed  more  serious  changes  than  the  segment 
treated  by  simultaneous  ligature  of  artery  and  vein.  Of  the  remaining  two  cases,  one 
showed  no  change  at  all.  consequent  upon  the  fact  that  too  short  a  segment  of  the 
bowel  had  been  deprived  of  its  blood  supply,  while  the  result  in  the  sixth  case  was 
complicated  by  the  development  of  an  acute  volvulus.'  " 

Dr.  D.  E.  Hooker  has  very  kindly  tested  for  me  in  the  dog  the  effect  on 

the  arterial  blood  pressure  in  the  vessels  of  the  leg  of  temporary  occlusion 

of  the  external  iliac  vein  after  ligation  of  the  corresponding  artery,  and 

sends  me  the  following  report :   "  The  saphenous  artery  (a  small  branch  of 

the  femoral)  was  cannulated  and  the  arterial  pressure  (femoral)  recorded. 

When  the  external  iliac  artery  was  ligated  the  pressure  promptly  fell  from 

*  "  Comptes  Rendus,  Conf.  Chir.  Interall.,  Paris,  1917,  p.  34S." 


LIGATION  OF  LEFT  SUBCLAVIAN  AETEEY  509 

11-4  to  26  mm.  Hg.  In  the  course  of  an  hour  the  pressure  rose  to  about 
50  mm.  Hg.,  but  the  point  of  interest  lav  in  the  response  of  this  pressure 
to  temporary  occlusion  of  the  external  iliac  vein,,  the  chief  arterial  supply 
to  the  part  remaining  shut  off.  In  six  observations  in  the  period  of  an  hour 
in  which  the  vein  was  occluded  from  one  to  eight  minutes  the  arterial  pres- 
sure rose  20,  12,  8,  3,  10,  and  14  mm.  Hg.  Deocclusion  of  the  vein  was  fol- 
lowed by  a  sudden  fall  in  pressure  and  a  subsequent  slow  rise.  This  rise, 
however,  never  reached  the  level  established  when  the  vein  was  occluded." 

The  necessity  for  maintaining  a  proper  balance  between  the  arterial  and 
venous  systems  is  suggested  by  the  prompt  diminution  of  the  swelling  of 
the  Limb  on  ligation  of  the  artery  feeding  the  pulsating  tumor.  In  the  case 
of  a  very  large  ilio-femoral  aneurism  the  swelling  of  the  thigh  and  leg 
rapidly  subsided  after  a  partially  occluding  band  had  been  applied  by  me 
to  the  external  iliac  artery.  Three  or  four  weeks  after  the  application  of 
the  band  the  aneurism  and  the  deep  and  superficial  femoral  veins  were 
excised.  These  veins  were  found  to  be  completely  occluded  by  the  tumor : 
hence  the  reduction  in  swelling  which  promptly  followed  the  ligation  of 
the  artery  could  not  have  been  due  to  relief  of  pressure  on  these  veins.  The 
operation  was  performed  about  five  years  ago.  The  patient,  a  stevedore, 
writes  that  the  function  of  the  Limb  is  perfect.  In  striking  contrast  to  this 
is  the  result  obtained  in  another  patient  whose  common  iliac  artery  I  ligated, 
many  years  ago.  but  not  the  corresponding  vein.  In  this  instance  the  patient 
was  prevented  by  claudication  from  ever  walking  more  than  one  or  two 
hundred  yards. 

We  are  compelled,  I  believe,  to  subscribe  to  the  view  that  some  degree  of 
equilibrium  of  the  arterial  and  venous  systems  must  be  maintained.  Grant- 
ing this,  there  vanishes  any  difficulty  that  there  may  have  been  in  accounting 
for  the  very  high  percentage  of  gangrene  observed  to  follow  ligation  of  the 
artery  in  cases  of  arterio-venous  fistula.  There  is  in  these  cases  not  only  a 
great  enlargement  of  the  venous  bed  but  also  a  curtailment  of  the  arterial 
tubage — a  shrinkage  or  hypoplasia  of  the  arteries  distal  to  the  fistula. 
Thus  even  before  the  artery  is  Ligated  the  limb  is  handicapped  by  this  lack 
of  balance.  When,  now,  the  artery  above  a  fistula  is  tied,  irrigation  with 
arterial  blood  is  suppressed  on  one  side  of  the  capillary  bed  and  on  the  other 
side  of  it  the  mixed  blood  is  deprived  of  a  share  of  the  pressure  by  virtue 
of  which  the  life  of  the  limb  was  partly  sustained.  It  seems  permissible  to 
conjecture  that  in  some  instances  the  limb  distal  to  the  fistula  may  have 
been  hardly  less  dependent  on  the  pressure  from  the  venous  than  from  the 
arterial  side,  and  if  so  we  can  more  readily  comprehend  the  ensuing  gangrene 
than  the  frequent  absence  of  it  after  ligation  of  the  fistuled  artery.  The 
gangrene,  almost  unprecedented  in  extent,  which  followed  the  remarkably 


510  LIGATION  OF  LEFT  SUBCLAVIAN  ARTEEY 

brilliant  operation  of  Matas  SB  for  the  cure  of  a  fistula  of  the  subclavian 
vessels  was  undoubtedly  intensified  by  the  fact  that  this  skilful  surgeon 
succeeded,  by  careful  suturing,  in  preserving  the  lumen  of  the  vein. 

The  reversed  picture  of  disbalance — the  obturated  vein  with  the  patulous 
artery — is  a  more  familiar  one. 

Ultimately  we  may  be  less  disinclined  to  ligate  arteries  for  the  relief  of 
swelling  due  to  occluded  veins — veins  plugged  by  carcinoma  or  thrombus. 
Our  thoughts  revert  to  the  important  contribution  of  Carnochan  *  who 
cured  a  case  of  elephantiasis  Arabum  by  ligation  of  the  femoral  artery,  and 
to  the  unpublished  experimental  work  of  Welch  and  Mall  *  on  intestinal 
infarction. 

Since  ligation  of  the  vein  raises  the  blood  pressure  in  the  ischaemic  area, 
is  it  not  possible  that  the  response  of  the  arterial  side  for  anastomotic  devel- 
opment may  be  delayed  or  lessened  for  a  period  and  to  a  degree  conform- 
able to  the  time  and  amount  that  the  obstruction  of  the  vein  contributes  to 
the  maintenance  of  the  circulation  of  the  extremity  ?  If  this  is  so,  might  not 
the  ligation  of  the  like-named  vein  be  postponed,  when  this  can  be  done 
without  danger,  in  order  not  to  relieve  the  arterial  side  of  its  responsibility  ? 
Then  if  after  a  time  there  should  be  evidence  of  disability  from  ischaemia, 
such  as  claudication  on  exercise,  the  surgeon  would  have  the  ideal  oppor- 
tunity to  demonstrate  the  value  of  the  venous  ligation. 

Another  possible  expedient  is  to  be  borne  in  mind.  A  metal  band  (alumi- 
num) might  be  applied  temporarily  to  the  vein.  The  pressure  within  veins 
is  so  slight  that  a  band  might,  perhaps,  without  producing  necrosis  as  of 
an  artery,  be  tolerated  for  weeks  or  months  or  indefinitely,  f  I  suggest  this 
as  an  experiment  which  might  help  to  solve  the  problem ;  but  first  we  must 
determine  how  long  a  totally  and  how  long  a  partially  occluding  band 
may  remain  on  the  wall  of  a  vein  without  bringing  about  its  permanent 
obturation. 

*  This  paper  will  be  included  in  "  Papers  and  Addresses  by  William  Henry  Welch," 
1920,  being  published  by  The  Johns  Hopkins  Press.  [This  publication  has  appeared. — 
Editor.] 

t  A  few  years  ago  Dr.  Reid  and  I,  at  his  suggestion,  applied  an  aluminum  band 
to  the  pulmonary  artery  of  a  dog.  reducing  the  lumen  of  this  vessel  by  about  one- 
half.  Eighteen  months  later  the  dog,  in  good  health,  was  sacrificed.  The  wall  of  the 
pulmonary  artery  was  found  to  be  nearly  intact;  only  at  one  point  on  its  proximal 
edge  had  the  band  perforated  the  wall  of  the  vessel.  The  lungs  were  apparently 
unaffected  by  the  diminished  supply  of  blood. 

About  ten  years  ago,  with  Dr.  James  F.  Mitchell  of  Washington,  I  partially  occluded 
with  an  aluminum  band  an  enormously  dilated  ilio-femoral  vein,  above  an  arterio- 
venous fistula,  after  a  prolonged  attempt  on  the  part  of  both  of  us  to  dissect  free  the 
involved  vessels.  Only  slight  relief  was  afforded  by  the  constriction  of  the  vein ;  and 
the  desperate  condition  of  the  patient  precluded  further  intervention. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  511 

Gangrene  has  so  rarely  followed  ligation  of  the  subclavian  and  common 
iliac  *  arteries  that  in  the  case  of  these  vessels  I  should  for  the  present  be 
disinclined  to  tie  off  simultaneously  the  corresponding  vein. 

Abstracts  of  the  Cases  of  Ligation  of  the  First  Portion  of  the 
Left  Subclavian  Artery.  Comments 

J.  Kearny  Rodgers.  (1.)  Case  of  ligature  of  the  left  subclavian  artery 
within  the  scalenus  muscle,  for  aneurism.  New  York  Journal  of  Medicine 
and  the  Collateral  Sciences,  1846,  vii,  219. 

"  Michael  Larman,  born  in  Germany,  aged  42  years,  was  admitted  under 
my  care,  into  the  Xew  York  Hospital,  September  13,  1845,  with  aneurism 
of  the  left  subclavian  artery.   The  account  he  gives  of  it  is  as  follows : 

'  About  four  weeks  ago,  when  carrying  a  basket  of  peaches  (containing  about  a 
bushel)  on  his  left  shoulder,  he  was  suddenly  seized  with  a  severe  pain  in  the 
shoulder  and  arm,  and  was  obliged  to  lay  down  the  basket.  On  examining  the  part,  he 
then,  for  the  first  time,  observed  a  swelling  above  the  clavicle,  about  the  size  of  a 
pullet's  egg.  Since  last  winter,  about  February,  he  had  suffered  pain  in  the  arm, 
and  observed  that  it  was  occasionally  swollen;  but  was  not  obliged  to  give  up  work.' 

"  On  examination,  a  pulsating  tumor  can  be  seen  above  the  left  clavicle, 
about  the  size  of  a  small  hen's  egg,  rising  beyond  the  bone  about  two  inches ; 
extending  externally  to  the  outer  third  of  the  clavicle,  and  internally,  covered 
by  the  outer  edge  of  the  sterno-mastoid  muscle.  Pulsation  was  very  distinct 
over  the  entire  surface  of  the  tumor.  The  cutaneous  veins  below  the  sternal 
end  of  the  clavicle  were  very  much  enlarged  and  their  coats  thickened.  There 
were  marks  of  cupping  over  the  shoulder. 

"  The  patient  complains  of  severe  pains  in  the  axilla,  extending  down  the 
arm  to  the  finger  ends.  He  cannot  sleep,  and  his  general  health  has  suffered 
from  the  want  of  rest,  being  obliged  to  walk  his  room  at  night  on  account 
of  the  severe  pain ;  the  left  arm  and  hand  are  swollen,  so  as  to  interfere  with 
the  flexion  of  the  fingers. 

"  There  was  no  perceptible  difference  in  the  pulse  at  the  wrists.  Its  beat 
was  92,  soft  and  full 

"  September  2S,  18^5. — A  consultation  of  the  surgeons  being  called,  they, 
after  a  full  discussion  of  the  case,  very  kindly  left  it  with  me  to  decide 
whether  the  operation  should  be  performed. 

"  The  tumor  continued  slowly  and  gradually  to  increase,  and  passed  more 
under  the  mastoid  muscle  than  on  his  admission,  so  as  to  give  me  some 
apprehension  of  trouble  from  it  in  the  operation. 

*It  is  still  believed  (Wolff,"  Matas,"  and  others)  that  ligation  of  the  common 
iliac  artery  is  followed  by  gangrene  in  from  33  to  50  per  cent  of  the  cases.  That  this 
belief  is  erroneous  is  proved  by  my  careful  study  of  each  reported  case.  On  page  215 
of  my  paper21  is  the  following  statement:  "Granted  that  in  the  cases  of  Lange 
and  Cranwell  the  ligation  of  the  artery  was  solely  responsible  for  the  gangrene,  we 
have  only  two  such  cases  in  the  thirty  of  my  collection,  a  percentage  of  six  and  six- 
tenths.  If  it  should  appear  later  that  CranwelTs  case  might,  for  unascertained  reasons, 
be  excluded,  the  percentage  would  be  three  and  three-tenths,  and  the  sum  total  of 
gangrene  the  cutaneous  necrosis  of  one  toe." 


512  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

"  He  was  apprised  of  the  fatal  nature  of  the  disease,  and  the  dangers 
of  an  operation,  but  his  sufferings  were  so  great  that  he  expressed  his  will- 
ingness to  undergo  whatever  operation  afforded  the  least  prospect  of  relief 
from  pain  and  of  restoration  to  health. 

"  Having  decided  on  tying  the  subclavian  artery,  I  summoned  my  col- 
leagues on  the  14th  of  October,  and  the  operation  was  performed  in  the 
theatre  of  the  hospital  at  1  p.  m.  of  that  day,  in  the  presence  of  Drs.  Mott 
and  Stevens,  consulting  surgeons,  of  Drs.  Cheesman,  Post,  Hoffman,  Buck, 
and  Watson,  surgeons,  and  an  assemblage  of  about  three  hundred  physicians 
and  students. 

"  The  patient  was  laid  on  a  low  bed,  with  his  head  and  shoulders  raised, 
and  his  face  turned  to  the  right  side.  The  light  from  the  dome  shone  directly 
on  the  part  to  be  operated  on. 

"  An  incision  was  made  three  inches  and  a  half  in  length  on  the  inner 
edge  of  the  mastoid,  terminating  at  the  sternum,  and  dividing  the  integu- 
ments and  platysma  myoides.  This  was  met  by  another  extending  along 
the  sternal  extremity  of  the  clavicle,  about  two  and  a  half  inches.  This  last 
incision  divided  a  plexus  of  varicose  veins  passing  in  the  integuments, 
covering  the  clavicle  to  the  subclavian.  Free  bleeding  taking  place  from 
their  cut  and  patulous  extremities,  it  became  necessary  to  check  it  by 
ligature. 

"  The  flap  of  integuments  and  platysma  myoides  was  now  dissected  up, 
and  the  lower  end  of  the  mastoid  laid  bare;  a  director  was  passed  under 
this  muscle,  and  the  sternal  portion  and  half  of  the  clavicular  divided  by  the 
bistoury.  This  muscle  was  now  turned  up,  and  the  sterno-hyoideus  muscle, 
the  omo-hyoideus,  and  the  deep-seated  jugular  vein  were  seen  covered  by 
the  fascia. 

"  On  turning  up  the  mastoid,  a  portion  of  the  aneurismal  sac  strongly 
pulsating  was  brought  into  view,  overlapping  about  half  the  width  of  the 
scalenus,  forming  now  the  outer  part  of  the  track  through  which  I  was  to 
pass,  showing  fearfully  one  of  the  dangers  of  the  operation,  which,  from 
my  previous  examination  of  the  part,  I  had  of  course  anticipated. 

"  The  fascia  being  divided  by  the  handle  of  the  scalpel  and  the  fingers, 
I  passed  in  contact  with  the  deep  jugular  on  its  outer  side  to  the  inner  edge 
of  the  scalenus  anticus,  intending,  for  the  purpose  of  avoiding  as  much  as 
possible  all  danger  to  the  thoracic  duct,  to  reach  this  muscle  fully  half  an 
inch  above  the  rib,  rather  than  at  its  insertion.  I  now  felt  distinctly  the 
phrenic  nerve  running  down  on  the  anterior  surface  of  the  scalenus,  and  was 
confident  that  I  should  be  able  to  avoid  any  injury  to  it.  Having  attained 
the  inner  edge  of  the  scalenus,  by  pressing  downwards  with  the  finger,  I  soon 
discovered  the  rib,  and  after  some  little  search  easily  found  the  subclavian 
artery.  By  pressing  it  against  the  rib,  all  pulsation  ceased  in  the  tumor,  and 
by  removing  the  finger,  pulsation  returned. 

"  I  now  felt  that  great  care  was  necessary  to  detach  the  artery,  and  avoid 
danger  to  the  pleura  and  thoracic  duct.  In  accomplishing  this  part  of  the 
operation,  I  at  first  tried  Sir  Philip  Crampton's  instrument,  but  ascertain- 
ing that  I  could  better  carry  the  ligature  around  the  artery  and  bring  up 
its  end,  by  the  invention  of  Drs.  Parrish,  Hewson,  and  Hartshorne,  of  Phila- 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  513 

delphia  (long  since  given  to  the  profession  by  them,  and  lately  claimed  by 
Mr.  PEstrange  of  Dublin),  I  accordingly  adopted  that  instrument. 

"  This  part  of  the  operation  it  will  be  imagined  was  not  very  readily 
accomplished.  The  great  depth  of  the  vessel  (nearly  the  length  of  my  fore- 
finger), and  narrowness  of  the  wound,  prevented  a  very  easy  management 
of  instruments.  The  point  was  introduced  under  the  artery,  and  soon 
directed  upwards  so  as  to  avoid  injury  to  the  pleura.  The  needle  carrying 
the  ligature  was  now  detached  from  the  shaft  of  the  instrument,  and  drawn 
upwards  so  as  to  include  the  artery.  I  readily  tied  the  ligature,  and  tightened 
it  with  the  forefingers  in  the  bottom  of  the  wound.  All  pulsation  immedi- 
ately ceased  in  the  aneurism  and  the  arteries  of  the  extremity. 

"  The  patient  complained  of  no  pain  or  unusual  feeling  in  the  head,  as 
might  have  been  expected  from  so  suddenly  changing  the  current  of  so  large 
a  quantity  of  blood 

"6th  day,  October  19-th wound  suppurating;  its  sutures  were 

removed;  ....  poultice  to  the  wound 

"  9th   day,    October   2 2d wound   doing   well,   and   suppurating 

freely 

"  i3th  day,  October  26th. — 2  a.  m.  The  patient,  on  changing  his  position 
from  the  right  side  to  his  back,  felt  a  trickling  down  his  chest  of  what  he 
supposed  was  matter,  but  which  the  nurse  ascertained  to  be  blood.  The 
house  surgeon  was  immediately  called,  and  controlled  the  haemorrhage  by 
filling  the  wound  with  layers  of  dry  hard  sponge,  placing  a  compress  over 
this,  and  securing  the  whole  by  a  bandage.  About  20  ounces  of  blood  were 
lost 

"  14th  day,  October  27th. — 6  a.  m.  There  has  been  no  bleeding  during 
the  night;  pressure  has  been  firmly  made  over  the  wound;  the  blood  has 
passed  under  the  integuments  of  the  neck  in  so  great  quantity  that  there 
is  a  decided  bulging  of  the  skin  on  the  left  side,  extending  to  the  back  of 
the  shoulder 

"  15th  day,  October  28th. — 6  a.  m On  removing  the  outer  sponge 

there  is  a  firm  clot  seen  which  for  a  time  controls  the  bleeding,  but  the 
least  effort  causes  a  free  gush  of  blood;  gentle  pressure  to  be  continued. 
1  p.  m.  The  clot  beneath  the  integuments  causes  so  much  pressure  on  the 
oesophagus  as  nearly  to  prevent  deglutition;  the  tendency  to  external 
haemorrhage  is  less,  and  the  external  clot  firm ;  there  is  danger  that  the  blood 
effused  may  press  on  the  larynx  sufficiently  to  prevent  respiration,  and  the 
pressure  was  accordingly  discontinued;  oozing  continues.  5  p.  m.  Patient 
dying ;  no  external  haemorrhage.  5^.  Died. 

"Postmortem  Examination,  Eighteen  Hours  After  Death. — The  wound 
was  filled  with  coagula  and  sponge,  which  had  been  introduced  for  the  pur- 
pose of  making  pressure.  The  blood  was  already  in  a  state  of  partial  decom- 
position. The  dissection  was  carefully  performed,  exposing  the  different 
layers  of  muscles.  The  lower  incisions  made  at  the  operation  were  found 
to  include  three-fourths  of  the  mastoid,  leaving  a  small  portion  of  the 
clavicular  portion  undivided.  Below  this  the  aneurismal  sac  and  the  scalenus 
anticus  formed  the  outer  and  posterior  wall  of  the  wound.  The  inner  wall 
was  formed  of  condensed  cellular  tissue  covering  the  carotid  artery,  jugular 
vein,  thoracic  duct,  and  the  edges  of  the  thyroid  muscle.  At  the  bottom  was 
34 


514  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

the  subclavian  artery,  completely  divided  by  the  ligature,  which  was  found 
free  in  the  coagula.   The  cellular  tissue  of  all  the  parts  around  the  wound 
was  condensed  by  adhesive  inflammation,  rendering  the  dissection  exceed- 
ingly tedious  and  difficult.   The  jugular  vein,  which  skirted  the  inner  wall 
of  the  wound,  was  obliterated  and  filled  with  fibrinous  coagula.    Opposite 
the  track  of  the  ligature  the  vein  was  contracted  to  a  cord,  and  impervious 
as  far  as  its  junction  with  the  subclavian.   The  vena  innominata  and  sub- 
clavian were  normal.    The  pleura  at  the  bottom  of  the  wound  presented  a 
large  irregular  lacerated  opening,  communicating  from  the  wound  with  the 
left  pleural  cavity,  which  was  filled  with  coagulated  blood.    This  formed 
one  large  uniform  coagulum,  and  had  every  appearance  of  being  of  rapid 
and  recent  formation ;  the  membrane  around  these  was  thickened.  On  expos- 
ing and  tracing  the  subclavian  artery,  it  was  found  that  the  ligature  had 
been  applied  about  one  and  a  quarter  inches  from  its  origin  at  the  aorta,  and 
immediately  at  the  root  of  the  vertebral,  on  its  cardiac  side.    The  artery 
had  been  completely  divided  by  the  ligature,  which  as  mentioned  above  was 
found  loose  in  the  wound.   The  stump  of  the  subclavian,  between  the  aorta 
and  ligature,  presented  the  appearance  of  a  round  solid  cord,  about  an  inch 
and  a  quarter  long,  and  impervious  to  liquids  or  air.   The  external  coat  of 
the  stump  was  thickened  and  adherent  near  the  ligature  to  the  surrounding 
tissues,  by  adhesive  inflammation.  On  laying  open  the  vessel  longitudinally 
it  was  found  that  a  firm  fibrinous  coagulum  occupied  the  vessel,  and  was 
adherent  firmly  to  its  inner  coat  for  three  quarters  of  an  inch ;  near  the 
aorta,  the  coagulum  was  softer.    The  coats  of  the  vessel  were  moderately 
thickened,  and  presented  a  small  patch  of  atheromatous  deposit  about  a 
third  of  an  inch  from  the  tied  end.  Around  this  deposit  the  adhesion  seemed 
as  perfect  as  at  any  other  part.   Beyond  the  ligature  the  vessel  presented  a 
different  appearance.  No  plug  other  than  a  soft  coagulum  of  blood  occupied 
its  cavity,  and  it  presented  much  less  evidence  of  adhesive  inflammatory 
process  in  its  coats.    The  vertebral  was  given  off  immediately  at  the  point 
of  ligature,  and  was  open,  containing  a  thin  blood  coagulum  like  the  one  in 
the  subclavian.   These  were  drawn  out  with  ease,  and  evidently  had  formed 
during  the  last  moments  of  life.  About  one  third  of  an  inch  from  the  ver- 
tebral came  off  the  thyroid  axis,  and  nearly  opposite  the  vertebral  was  the 
internal  mammary.    These  vessels  were  all  patulous  and  healthy.    About 
half  an  inch  from  the  thyroid  axis  commenced  the  dilatation  of  the  artery 
to  form  the  aneurismal  sac.    This  tumor  was  about  the  size  of  a  small 
orange,  and  had  involved  in  its  growth  part  of  the  scalenus  anticus,  the 
cervical  nerves  going  to  form  the  cervical  plexus,  the  surrounding  cellular 
tissue,  and  the  glands.    The  aneurism  was  completely  blocked  up  with 
coagula,  and  the  axillary  artery  which  emerged  from  its  distal  side  was 
plugged  with  a  fibrinous  clot  exactly  similar  to  the  one  in  the  stump  of  the 
subclavian,  though  perhaps  not  so  perfect.    It  appeared  sufficiently  so, 
however,  to  obliterate  entirely  the  calibre  of  the  vessel.   The  plug  extended 
some  distance  down  the  axillary  artery.   The  thoracic  duct,  which  had  been 
injected  with  wax  from  the  abdomen,  was  found  uninjured.   The  aorta  was 
thickened,  and  its  coats  irregular  from  a  considerable  deposit  of  atherom- 
atous matter  in  its  tissues.    The  heart  was  somewhat  larger  than  natural, 
but  apparently  sound.   The  other  organs  were  not  examined,  as  the  friends 
insisted  on  an  early  removal  of  the  body  for  burial. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  515 

"  Although  a  decided  majority  of  the  consultation  agreed  as  to  the  pro- 
priety of  the  operation  of  securing  the  artery  for  aneurism,  still,  as  my 
colleagues  kindly  left  it  with  me  to  decide  whether  it  should  be  under- 
taken, I  felt  it  incumbent  on  me  to  investigate  the  subject  with  great  care, 
and  accordingly  gave  it  my  most  sedulous  attention.  I  was  the  more  anxious, 
because,  in  the  only  case  in  which  the  attempt  had  been  made  by  Sir  Astley 
Cooper,  in  1809,  that  eminent  surgeon  failed  of  securing  the  vessel,  and  is 
said  to  have  entertained  apprehensions  that  he  had  wounded  the  thoracic 
duct. 

"  I  had  always  considered  it  as  a  perfectly  justifiable  operation,  and  one 
that  a  careful  surgeon  conversant  with  anatomy  could  accomplish,  if  the 
tumor  were  of  a  moderate  size. 

"  The  want  of  success  in  the  four  or  five  operations  on  the  right  sub- 
clavian in  its  first  stage  did  not  discourage  me,  nor  did  they  alter  my 
opinion.  The  difference  in  the  anatomy  of  the  right  and  left  arteries  was 
so  very  great,  that  I  did  not  consider  it  fair  to  argue  that  a  similar  result 
was  to  follow  on  the  left  side.  The  greater  depth  of  the  left,  indeed, 
rendered  the  operation  more  formidable,  but,  if  accomplished,  not  less  likely 
to  succeed. 

"  The  point  where  the  ligature  must  necessarily  be  applied  on  the  right 
side  is  but  a  quarter  or  at  most  half  an  inch  from  the  innominata  and  the 
coming  off  of  the  carotid ;  so  that  it  could  scarcely  be  expected  that  a  coagu- 
lum  would  form  sufficiently  firm  to  adhere  to  the  vessel,  and  resist  the  force 
of  the  heart's  action.  Besides,  too,  the  greater  force  of  the  circulation  on  the 
right  side  was  additionally  unfavorable  to  success  on  that  vessel,  and,  there- 
fore, is  an  additional  reason  for  distrusting  an  argument  drawn  from  a 
parallel  between  the  two. 

"  In  examining  anatomical  and  surgical  authorities  I  found  the  opinion 
prevalent  among  almost  all  British  authors  that  the  operation  on  the  left 
side  was  '  impracticable/ 

"  Colles,  the  eminent  Irish  surgeon  who  first  tied  the  right  subclavian  in 
its  first  stage,  says: 

'  This  operation,  difficult  on  the  right,  must  be  deemed  impracticable  on  the  left 
subclavian.  For  the  great  depth  from  the  surface  at  which  this  vessel  is  placed — the 
direct  course  which  it  runs  in  ascending  to  the  top  of  the  pleura — the  sudden  descent 
which  it  makes  from  this  to  sink  under  the  protection  of  the  clavicle,  and  the  danger 
of  including  in  the  same  ligature  the  eighth  pair  of  nerves,  the  internal  jugular  vein 
or  the  carotid,  which  all  run  close  to,  and  nearly  parallel  with,  this  artery;  these  all 
constitute  such  a  combination  of  difficulties  as  must  deter  the  most  enterprising  sur- 
geon from  undertaking  this  operation  on  the  left  side.' — Edinburgh  Med.  and  Surg. 
Journal,  Jan.  7,  1815,  p.  23. 

"  Harrison,*  Flood,  f  Guthrie,J  and  Quain,§  all  coincide  in  this  opinion. 

"  The  opinions  of  those  eminent  anatomists  and  surgeons  being  so  decid- 
edly against  the  possibility  of  the  operation,  it  was  only  left  for  me  to 
examine  with  great  care  the  surgical  anatomy  of  this  vessel. 

♦"Harrison  on  the  Anatomy  of  the  Arteries.  Dublin:  1833.  vol.  i,  p.  125." 
t "  Flood.  The  Surgical  Anatomy  of  the  Arteries.  London:   1839,  p.  84." 
t "  C  J.  Guthrie  on  the  Diseases  and  Injuries  of  the  Arteries,  etc.  London.  1830, 
p.  396." 

§  "  Quain's  Anatomy,  3d  edition.    London:  p.  492." 


516  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

"  Having  had  the  thoracic  duct  injected  with  wax,  I  repeatedly  dissected 
the  parts  concerned,  and  operated  in  every  way  that  suggested  itself  to  me 
as  likely  to  present  any  advantages.  My  opinion  of  its  feasibility  was  thus 
confirmed,  and  having  never  entertained  any  doubts  of  its  propriety,  I 
accordingly  undertook  it. 

"  I  regret,  indeed,  deeply,  the  death  of  my  patient,  but  the  appearances 
presented  on  examination  after  death,  have  only  strengthened  the  opinion 
I  had  previously  formed,  and  have  encouraged  me  to  undertake  it  with  some 
slight  variations,  should  another  case  ever  present  itself. 

"  It  has  often  happened  with  important  operations  that  many  of  the 
first  cases  have  been  unsuccessful,  while  the  carefully  noted  observations 
made  on  dissection  have  led  to  different  modes  of  operating,  and  more 
uniform  success. 

"  Previously  to  the  performance  of  this  operation  many  entertained  doubts 
whether  the  force  of  the  circulation  so  near  the  heart  in  so  large  a  vessel 
would  not  prevent  the  formation  of  a  coagulum,  and  of  course  interfere  with 
the  obliteration  of  the  vessel. 

"  These  doubts  have  now  been  removed,  and  I  consider  that  all  reasonable 
objections  fall  with  them,  except  those  arising  from  the  anatomy. 

"  Danger  to  the  thoracic  duct  and  pleura  are  in  my  opinion  the  most 
serious  of  these,  for,  with  ordinary  coolness  and  care,  there  will  be  little 
danger  of  including  the  pneumogastric  and  phrenic  nerves,  or  carotid  artery, 
in  the  ligature.  The  veins  may  be  lacerated  by  great  roughness,  but  can 
scarcely  be  included. 

"  The  thoracic  duct,  I  think,  can  almost  always  be  avoided  by  reaching 
the  inner  edge  of  the  scalenus  half  or  three  quarters  of  an  inch  above  its 
insertion,  and  then  pressing  the  finger  down  towards  the  rib.  The  duct  is 
thus  kept  out  of  the  way  of  laceration  by  the  finger,  and  afterwards  by  the 
aneurismal  needle.  I  am  aware  that  this  duct  varies  in  its  course,  but  this 
direction  I  am  confident  will  usually  secure  its  safety.  By  adopting  it  in 
the  many  times  I  operated  and  dissected  the  parts  in  the  dead  body,  it  was 
uninjured. 

"  The  artery  lies  in  contact  with  the  pleura,  the  laceration  of  which  might 
be  attended  with  very  distressing  and  dangerous  consequences.  A  careful 
introduction  of  the  aneurismal  needle,  and  soon  turning  up  its  point,  will 
usually  secure  the  safety  of  this  membrane.  In  none  of  my  operations  on 
the  dead  body,  where  it  was  performed  in  this  way,  was  it  injured. 

"  The  haemorrhage  in  this  case  came  from  the  distal  end  of  the  artery, 
and  the  very  free  and  direct  anastomosis  of  the  internal  carotid  at  the  base 
of  the  brain  with  the  vertebral  induce  me  to  think  that  it  was  the  latter 
vessel  which  transmitted  the  blood.  Some  indeed  may  have  come  through 
the  thyroid  axis,  but  I  consider  the  former  mode  more  direct. 

"  Should  this  operation  be  repeated,  I  would  suggest  the  securing  of  the 
vertebral,  and  if  possible  the  thyroid  axis,  by  ligature.  The  difficulties  are 
indeed  thus  increased,  but  not  insurmountable. 

"  I  present  this  case  to  the  profession  with  the  confident  hope  that  they 
will  give  it  their  approval.  I  do  not  covet  the  empty  honor  of  performing 
for  the  first  time,  be  it  ever  so  skilfully,  any  operation,  however  bold  and 
difficult,  but  of  doing  that  which,  though  once  unsuccessful,  will,  from  the 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  517 

knowledge  thence  derived,  enable  us  to  enlarge  our  sphere  of  usefulness, 
and  be  the  means  of  preserving  human  life." 

V.  Marchesano.  (II.)  Legatura  della  succlavia  sinistra  fra  la  trachea 
e  gli  scaleni.  L'Osservatore  Medico,  Palermo,  1875,  vol.  v,  p.  327. 

"  On  the  evening  of  July  17,  1875,  a  carpenter,  aet.  34,  presented  him- 
self at  the  Ospedale  di  S.  Francesco. 

"  He  was  covered  with  bloody  old  clothes,  and  with  his  right  hand  pressed 
a  wound  which  he  had  received  a  few  moments  before  in  the  left  side  of  the 
neck.  The  wound,  he  said,  had  been  made  by  a  blow  from  a  chisel;  it  was 
immediately  followed  by  abundant  haemorrhage  which  was  partly  or  entirely 
controlled  by  the  hand  of  the  wounded  man  himself  so  that  he  could  be 
carried  to  the  hospital.  Having  arrived  there,  the  ward  surgeon  found  a 
freely  bleeding  wound  in  the  left  supraclavicular  triangle. 

"  This  wound  was  about  4  or  5  cm.  from  the  superior  border  of  the 
clavicle,  and  2  cm.  from  the  posterior  border  of  the  sternomastoid. 

"  The  surgeon  of  the  ward  dilated  the  wound  with  the  intention  of  prac- 
tising direct  ligature,  but  not  having  succeeded,  he  made  compression,  and 
in  view  of  the  gravity  of  the  case  sent  for  the  head  surgeons  of  the  hospital. 
"  I  was  the  first  to  arrive,  and  from  the  quantity  of  blood  which  accom- 
panied the  discontinuance  of  the  compression  concluded  that  we  had  to  con- 
tend with  a  haemorrhage  proceeding  from  one  of  the  superior  branches  of 
the  subclavian,  and  probably  of  the  posterior  scapular. 

"  The  wound  was  very  deep ;  the  finger  of  the  observer  did  not  fall  on  the 
bony  plane  formed  by  the  anterior  part  of  the  cervical  portion  of  the  verte- 
bral column,  but  ran  along  the  transverse  processes  of  the  vertebrae.  By 
pressing  on  the  posterior  face  of  these  apophyses  I  could  so  hook  the  finger 
as  to  arrest  the  haemorrhage  because  in  this  attitude  compression  was 
exerted  from  without  inwards  upon  the  muscles  which  are  inserted  in  the 
transverse  processes.  The  blood  came  out  through  the  fibres  of  these 
muscles,  not  in  a  direct  jet  as  when  a  wounded  artery  is  laid  bare,  but 
'  a  nappo,'  as  if  the  jet,  before  coming  into  view,  had  encountered  an  obstacle. 
"  Considering  the  serious  predicament  in  which  one  would  surely  find 
oneself  in  case  it  were  not  possible  by  the  direct  means  to  arrest  this  haemor- 
rhage, I  decided  that  it  was  justifiable  to  have  recourse  to  any  method  which 
might  be  of  service ;  I  therefore  practised  anew  the  dilatation  of  the  wound, 
with  the  object  of  discovering  definitely  the  vessel  from  which  the  blood 
came  and  in  order  to  be  able  to  manoeuvre  with  greater  ease ;  but  in  spite 
of  this  dilatation  it  was  impossible  for  me  to  discover  and  seize  the  wounded 
vessel  or  even  to  grasp  it  by  the  inclusion  of  tissues. 

"  I  had  manoeuvred  for  about  20  minutes,  when  Prof.  Errico  Albanese 
happened  in,  who  for  about  the  same  period  of  time  repeated  the  same 
manoeuvre  with  the  same  lack  of  success.  As  the  patient  had  already  lost 
much  blood,  we  agreed  to  make  use  of  a  tampon  of  cotton  saturated  with 
perchloride  of  iron,  combining  by  this  procedure  the  effects  of  compression 
and  of  a  styptic.  But  although  applied  with  the  greatest  care,  the  tampon 
did  not  check  the  haemorrhage  even  for  a  moment,  hence  it  was  necessary, 
in  order  that  we  should  not  see  the  patient  die  beneath  our  eyes,  to  decide 


518  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

to  ligate  the  subclavian  between  the  trachea  and  the  scaleni.  I  adopted  the 
process  used  by  Mott  for  ligating  the  innominate,  which  consists,  as  you 
know,  in  making  two  incisions  which  join  at  an  angle  in  the  neck,  one  of 
which  runs  along  the  internal  border  of  the  sternomastoid  muscle  for  a  dis- 
tance of  5  cm.,  and  the  other  over  the  clavicle  as  far  as  the  clavicular  inser- 
tion of  this  muscle,  and  in  incising  finally  the  sternal  portion  of  the  sterno- 
mastoid, the  middle  cervical  aponeuroses,  and  the  tracheal  muscles,  thus 
reaching  the  artery.  Therefore,  since  it  is  my  principle  to  avail  myself  of 
all  possible  means  in  carrying  out  an  operation,  and  since  it  was  a  case  of 
ligating  the  left  subclavian  in  the  first  portion,  at  night  and  by  artificial 
light,  and  since  we  had  to  manoeuvre  in  the  vicinity  of  vital  organs  such  as 
the  internal  jugular  vein,  the  subclavian  vein,  the  pneumogastric  nerve,  and 
the  common  carotid,  I  made  the  transverse  incision  longer  than  is  prescribed 
by  Mott,  dividing  a  good  part  of  the  clavicular  portion  of  the  sternomastoid, 
the  tracheal  muscles,  and  more  than  the  internal  half  of  the  scalenus  anticus. 

"  At  the  moment  when  I  cut  the  fibres  of  the  scalenus  anticus,  I  had 
Dr.  Perni  draw  aside  the  phrenic  nerve  with  a  blunt  hook.  Opening  the 
sheath  of  the  artery  I  pushed  as  far  inwards  as  I  could  the  Cooper  needle 
armed  with  a  ligature. 

"  Assured  that  the  tightening  of  the  ligature  controlled  the  haemorrhage, 
the  direct  compression  which  had  been  practised  during  the  operation  was 
released  and  the  ligature  tied.  The  operation  was  accomplished  without 
serious  accident. 

"  July  18,  1875. — The  temperature  of  the  left  arm  was  the  same  as  that 
of  the  rest  of  the  body.  July  24,  1875 :  In  the  middle  of  the  night  there  was 
a  haemorrhage,  which  was  controlled  by  tampon  and  compression.  Two 
hours  later  another  haemorrhage  occurred,  which  was  controlled  by  the  same 
means.  July  25,  1875  :  Another  haemorrhage,  this  time  very  serious.  Com- 
pression and  perchloride  controlled  this  also.  The  patient  was  menaced  with 
syncope.  On  July  30th  there  was  noticed  a  small  collection  of  purulent 
matter  in  the  superior  third  of  the  internal  region  of  the  arm.  A  small 
incision  was  made,  also  lavage  with  disinfectants.  On  August  6,  1875,  the 
patient's  condition  seemed  to  be  fair  and  the  wound  of  good  aspect,  but 
during  the  night  at  2.30  a.  m.  there  suddenly  occurred  a  tremendous  haemor- 
rhage from  the  site  of  the  ligature,  and  in  a  few  moments  the  patient  died. 

"  Autopsy. — The  ligature  had  been  applied  40  mm.  from  the  arch  of  the 
aorta,  exactly  at  the  point  where  the  subclavian  artery  departs  from  the 
vertical  direction  to  turn  outwards.  The  vertebral  artery  arose  7  mm.  inside 
of  the  point  of  ligature,  and  immediately  behind  thise  arose  the  ascending 
cervical  with  an  independent  origin;  5  mm.  inside  of  the  ligature  the 
inferior  thyroid  afose.  All  the  other  arteries  springing  from  the  subclavian 
arose  distal  to  the  ligature.  The  two  scapulars,  the  superior  and  the  pos- 
terior, arose  from  a  common  trunk,  which,  situated  3  mm.  outside  of  the 
ligature,  after  a  course  of  23  mm.  running  from  in  front  towards  the  back 
and  crossing  the  nerves  of  the  brachial  plexus,  bifurcated  and  gave  rise  to 
them.  This  trunk  was  intact,  but  the  posterior  scapular  was  cut  6  mm.  from 
its  origin.  The  origins  of  the  left  subclavian  and  the  left  common  carotid 
were  1  cm.  apart.  The  ligature  at  the  site  of  the  ligation  was  not  found; 
perhaps  it  had  been  removed  with  the  debris  in  the  dressings  in  the  hurried 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  519 

examination  which  I  made  of  the  cadaver.    At  the  point  of  ligation  the 
artery  was  completely  cut  through  in  jagged  fashion." 

L.  C.  Lajte.  (III.)  Ligations  done  for  the  cure  of  aneurism.  Pacific 
Medical  and  Surgical  Journal,  San  Francisco,  1883-84,  vol.  xxvi,  p.  145. 

Page  149.  "  Subclavian  Artery. — 1.  An  engineer  from  a  Sandwich  Island 
plantation  was  brought  from  the  Islands  in  an  ambulance  litter,  afflicted 
with  aneurism  involving  the  termination  of  the  left  subclavian  and  the 
entirety  of  the  axillary  artery.  The  tumor,  large  as  a  fetal  head,  had 
apparently  only  the  cutis  for  external  wall.  Through  a  quadrangular  cut, 
the  flap  being  attached  above,  the  subclavian  was  reached  in  its  trans-scalene 
site,  and  tied  close  to  the  muscle.  Ligature  was  of  small  silk,  carbolized, 
ends  cut  short  and  wound  closed.  The  wound  healed  in  two  weeks  and  recov- 
ery was  complete  in  two  months.  Toda3r,  eighteen  months  after  the  ligation, 
the  man  writes  that  the  tumor  has  disappeared,  his  arm  is  restored,  and  he 
is  doing  his  work  as  an  engineer." 

Although  the  ligation  in  this  instance  quite  surely  was  not  of  the  first 
portion  of  the  artery,  the  quotation  from  Dr.  Lane's  brief  report  is  given 
because  it  supplies  the  missing  details  of  the  first  operation  performed  in 
the  second  case.  Reciprocally,  the  description  of  the  second  operation  in  the 
second  case  makes  it  quite  clear  that  Lane  did  not  ligate  the  first  portion  of 
the  subclavian  in  the  first  of  his  two  cases. 

"  2.  A  miner  from  Alaska,  with  similar  aneurism,  though  one-third  less 
in  volume,  had  the  left  subclavian  ligated  similarly,*  except  that  the  vessel 
was  reached  through  a  vertical  cut.  In  one  week,  primary  union  of  the 
wound.  The  man,  of  obstinate  temper,  near  the  end  of  the  second  week, 
though  cautioned  to  maintain  quiet,  rose  from  his  bed  and  used  the  close 
stool.  A  slight  bleeding  ensued  through  the  reopened  wound ;  later,  another 
violent  bleeding  occurred.  On  the  fourteenth  day  the  wound  was  opened, 
and,  while  the  blood  that  gushed  from  the  distal  end  was  controlled  by 
sponge  used  as  a  tampon,  the  artery  was  exposed  by  severing  the  sternal  leg 
of  the  sternocleidomastoid  muscle,  and  a  thread  thrown  around  the  sub- 
clavian just  as  it  emerges  from  the  thorax.  This  so  arrested  bleeding  that 
a  ligature  was  passed  around  the  vessel  close  to  the  aneurism  on  the  proximal 
side.  Though  there  was  no  more  haemorrhage,  and  the  vitality  of  the  arm 
was  well  maintained,  yet  the  man  died  from  exhaustion  on  the  19th  day 
after  the  first  ligation.  It  should  have  been  remarked  that  before  this  man 
came  under  my  care,  there  had  been  made  an  unsuccessful  attempt  to  cure 
him  by  indirect  compression  digitally  applied,  at  the  point  where  ligation 
was  afterwards  done." 

If  the  left  subclavian  was  ligated  by  this  "thread  thrown  around"  it 
"  just  as  it  emerges  from  the  thorax,"  Lane  was  the  first  to  ligate  the  first 
part  of  this  artery  for  the  arrest  of  haemorrhage.  If  the  thread  was  merely 

*  Between  the  scaleni  muscle  (vid.  Case  1). 


520  LIGATION  OP  LEFT  SUBCLAVIAN  ARTERY 

a  provisional  loop  and  not  tied,  then  we  should  not  credit  him  with  a  liga- 
tion of  the  left  subclavian  in  its  first  portion. 

Undoubtedly  the  haemorrhage  took  place  from  the  subclavian  at  the  site 
of  the  original  ligature  and,  if  so,  two  ligatures  must  have  been  applied  at 
the  second  operation,  the  one,  as  Lane  says,  proximal  and  close  to  the  aneu- 
rism, the  other  probably  being  the  "  thread  thrown  around  the  subclavian 
just  as  it  emerges  from  the  thorax." 

Inasmuch  as  the  two  ligatures  applied  at  the  second  operation  (one 
proximal  to  the  branches  of  the  first  portion,  the  other  to  the  third  portion, 
proximal  and  close  to  the  axillary  aneurism)  controlled  the  haemorrhage, 
we  must  conclude  that  the  bleeding  occurred  only  from  the  distal  end  of 
the  artery  divided  or  at  least  cut  into  by  the  original  ligature ;  for  had  the 
proximal  end  been  open,  the  haemorrhage  would  not  have  been  checked  by 
the  ligature  "  thrown  around  "  the  subclavian  just  at  its  point  of  emergence 
from  the  thorax,  nor  would  the  two  ligatures  applied  at  the  second  operation 
have  sufficed ;  it  would  have  been  necessary  to  close  the  central  stump  of  the 
artery  cut  through  by  the  primary  ligature. 

It  would  not  have  been  surprising  if  the  result  in  Lane's  first  case  had 
been  disastrous,  as  it  was  in  the  second,  for  he  tied  the  artery  with  "  small  " 
silk.  Many  times  have  I  warned  against  the  use  of  a  fine  thread  of  any  kind 
for  the  ligation  of  large  arteries,  particularly  for  ligation  in  continuity. 
The  danger  from  this  we  have  had  opportunities  to  observe  in  the  course  of 
our  experiments  on  dogs.  The  fatal  result  in  Lane's  second  case  may  have 
been  due  primarily  to  the  fineness  of  the  silk.  This  was  quite  surely  the 
cause  of  the  haemorrhage  if  infection  can  be  excluded.  But  infection  may 
well  have  played  a  part  from  the  outset  notwithstanding  the  fact  that  the 
wound  is  believed  to  have  healed  per  primam.  The  act  of  getting  out  of  bed, 
to  which  the  surgeon  attributes  the  haemorrhage,  could  hardly  have  been 
the  only  or  even  the  chief  factor  in  bringing  about  the  fatal  result. 

Bernard  Bardenheuer.  (IV.)  Die  Verletzungen  der  oberen  Extremi- 
taten.  Deutsche  Chirurgie,  Stuttgart,  1886,  Lieferung  63a,  Theil  I,  p.  445. 

"  Heinrich  Grenberg,  47  years  old,  had  a  very  large  hard  tumor  in  the 
left  supraclavicular  fossa.  I  pronounced  it  to  be  a  carcinoma  having  origin 
in  the  internal  jugular  vein.  The  tumor  extended  inwards  to  the  central 
plane,  the  larynx  was  pushed  far  to  the  right ;  above,  the  tumor  was  one  inch 
removed  from  the  mastoid  process,  outside,  it  came  in  contact  with  the  outer 
border  of  the  trapezius,  and  below,  it  disappeared  behind  the  clavicle,  or, 
rather,  the  manubrium  sterni ;  it  was  in  toto  rather  freely  movable  on  the 
underlying  parts.  Above  the  tumor  one  felt  the  pulsating  common  carotid, 
likewise  the  radial  artery  pulsating  synchronously  and  in  equal  strength 
with  the  coresponding  vessel  of  the  other  side.   There  was  no  oedema  of  the 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  521 

arm.  Behind  the  clavicle  one  heard  vesicular  breathing.  The  mobility  of 
the  tumor,  the  presence  of  pulsation  in  the  common  carotid  above  the 
tumor,  the  presence  of  pulsation  in  the  radial  artery,  the  absence  of  dis- 
turbance on  the  part  of  the  brachial  plexus,  led  me  to  the  opinion  that  a 
cure  of  the  tumor  might  be  effected  without  •wounding  one  of  the  vital 
organs;  tentatively,  I  proposed  to  ligate  the  arteries  centrally.  I  did  not 
fear  to  wound  the  pleura — which  I  knew  was  possible — after  my  own  experi- 
ence and  after  the  contributions  of  Konig 

"  To  sum  up,  it  evolved  that  the  tumor  was  much  more  extensive  than  I 
had  supposed.  The  carotid  artery,  the  subclavian  artery,  the  internal  jugular 
vein,  and  the  subclavian  vein  entered  the  tumor.  I  decided  to  ligate  the 
common  carotid  and  the  subclavian  in  its  first  portion,  a  ligation  which 
ranks  with  the  ligation  of  the  innominate  artery. 

"  I  accordingly  resected  half  the  clavicle,  a  piece  of  the  first  rib  2  inches 
long,  a  piece  of  the  manubrium  sterni  2  inches  broad  and  1^  inches  high, 
and  hereupon,  after  having  cut  through  the  sternomastoid,  sternothyroid, 
and  sternohyoid  muscles,  likewise  the  posterior  layer  of  the  fascia  profunda 
diagonally,  and  the  periosteum  vertically  in  the  whole  exposed  space,  I  had 
the  subclavian  vein,  the  jugular  vein,  the  junction  of  these  two,  and  the  left 
innominate  vein  lying  freely  before  me.  Since  the  veins  ran  into  the  tumor, 
I  ligated  first  the  left  innominate  vein  in  order  to  guard  against  the  aspira- 
tion of  air.  After  double  ligation  of  the  left  innominate  vein  the  common 
carotid  was  doubly  ligated  directly  behind  the  sternoclavicular  articulation 
and  cut  through.  The  subclavian  artery  at  this  point  lay  unusually  deep  and 
was  pushed  still  further  back  by  the  tumor. 

"  The  pleura  inflated  greatly  with  each  inspiration.  At  last  I  freed  the 
subclavian  artery  from  the  surrounding  tissues  below  inwards  and  behind 
and  doubly  ligated  it,  at  the  most  1.5  cm.  from  the  arch  of  the  aorta. 

"  The  operation  was  performed  with  the  greatest  ease  and  comfort  as  soon 
as  I  had  oriented  myself  as  to  the  location  of  the  subclavian ;  however,  it  is 
incomprehensible  to  me  how  one  is  able  to  complete  the  ligation  with  any 
surgical  satisfaction  and  certainty  without  this  extensive  exposure.  After 
the  ligation  of  the  innominate  vein,  of  the  common  carotid,  and  of  the  sub- 
clavian (central),  and  after  ligation  of  the  subclavian  vein,  the  internal 
jugular,  the  common  carotid,  and  the  subclavian  (peripheral),  the  operation 
was  easily  completed.  The  whole  procedure  consumed.  l-£  hours.  Unfortu- 
nately, the  vagus  nerve,  which  emerged  from  the  tumor,  had  to  be  cut 
through;  likewise  the  jugular  trunk  of  the  lymphatic  system  in  the  neigh- 
borhood of  the  transverse  process  of  the  third  or  fourth  cervical  vertebra  was 
opened,  so  that  a  stream  of  lymph  poured  into  the  wound. 

"  In  the  thorax  it  was  very  easy  to  avoid  wounding  the  thoracic  duct,  like- 
wise the  transparent  pleura  fluttering  back  and  forth :  altogether  the  opera- 
tion was  accomplished  with  the  same  ease  and  calm  as  at  the  dissecting  table. 

"  The  patient  recovered  somewhat  after  the  operation  and  felt  relatively 
well  and  had  no  dyspnoea;  nevertheless  he  collapsed  suddenly  18  hours 
thereafter,  having  said  a  short  time  before  death  that  he  felt  quite  well." 

There  is  no  pathological  report. 


522  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

W.  S.  Halsted.  (V.)  Ligation  of  the  first  portion  of  the  left  subclavian 
artery  and  excision  of  a  subclavioaxillary  aneurism.  Johns  Hopkins  Hos- 
pital Bulletin,  Baltimore,  1892,  vol.  iii,  p.  93. 

"  Surg.  No.  1589.  Levin  Waters  (Plate  XXYII),  colored,  aet.  '  52  »  (  ?) 
years,  was  admitted  to  The  Johns  Hopkins  Hospital  April  30,  1892.  Patient 
is  a  vigorous  man,  gives  a  good  family  history  and  denies  having  had  syphilis. 
Was  perfectly  well  until  eight  months  ago ;  he  then  noticed  a  small  swelling 
about  the  size  of  a  Madeira-nut  under  the  left  clavicle.  He  is  sure  that  there 
was  at  this  time  a  distinct  pulsation  in  the  tumor.  He  c  could  feel  it  beat  like 
my  heart '  when  he  put  his  finger  upon  it.  The  tumor  has  grown  rapidly  since 
it  was  first  observed.  Until  one  month  before  the  operation  the  patient 
worked  regularly,  did  heavy  lifting,  etc.,  and  had  experienced  little  or  no 
discomfort  from  the  aneurysm.  His  only  symptoms  were  a  slight  numbness 
in  the  left  hand  and  forearm,  and,  subsequently,  a  shortness  of  breath  and  a 
hoarseness — both  of  which  he  attributed  to  a  cold. 

"  Patient  says  that  he  has  never  had  a  pain  which  could  be  referred  to  the 
tumor. 

"  On  admission  the  patient  had  an  almost  spherical,  perfectly  smooth 
tumor  under  the  left  clavicle.  It  was  somewhat  flattened  on  the  side  which 
pressed  against  the  chest  wall,  and  measured  42  cm.  in  circumference  at  its 
base.  The  middle  third  of  the  clavicle  was  overlapped  and  almost  concealed 
by  the  tumor. 

"  Internally  the  tumor  extended  to  within  5  cm.  of  the  left  sterno- 
clavicular articulation,  and  externally  to  within  4  cm.  of  the  coracoid  process. 
It  was  only  after  careful  inspection  that  pulsation  could  be  seen.  To  the 
touch  the  tumor  was  quite  solid  but  elastic,  and  it  was  not  easy  to  appreciate 
the  feeble  expansile  pulsation.  Xo  pulse  could  be  felt  at  the  wrist  nor  any- 
where below  the  aneurism.  The  left  arm  was  neither  swollen  nor  perceptibly 
cooler  than  the  right. 

"  Operation,  May  10,  1892. — The  skin  incisions :  1.  Horizontal,  about 
33  cm.  long,  from  the  sternal  notch  to  the  acromioclavicular  articulation, 
and  thence  down  the  arm  to  the  lower  border  of  the  major  pectoral  muscle 
over  the  greatest  convexity  of  the  tumor.  2.  Ascending,  vertical,  about 
5  cm.  long,  from  the  inner  end  of  the  horizontal  incision.  3.  Descending, 
vertical,  about  10  cm.  long,  from  the  middle  of  the  horizontal  incision. 
4.  Ascending,  vertical,  about  4  cm.  long,  from  the  horizontal  incision  at  the 
acromioclavicular  articulation. 

"  The  flaps  so  outlined  were  reflected :  The  first,  upwards  and  outwards ; 
the  second,  downwards  and  inwards;  the  third,  downwards  and  outwards. 
The  inner  third  of  the  clavicle  was  then  excised.  Its  middle  third  was  some- 
what eroded  by  the  aneurism  which  slightly  overlapped  it. 

"  The  wall  of  the  aneurism  was  inflamed,  soft,  and  so  very  thin  where  it 
pressed  upon  the  bone  that  it  would  have  been  imprudent  to  attempt  to  dis- 
sect this  part  of  the  clavicle  from  the  tumor. 

"  The  next  step  in  the  operation  was  the  deligation  of  the  first  portion 
of  the  left  subclavian  artery.  This  portion  of  the  artery  had  been  drawn 
down  by  the  tumor,  so  as  to  occupy  a  horizontal  position  rather  than  a  ver- 
tical one.  It  was  entirely  concealed  by  the  subclavian  vein,  and  lay  below 
and  behind  the  vein  instead  of  above  and  behind  it.  I  thought  for  a  moment 


LIGATION  OF  LEFT  SUBCLAVIAN  AETERY  523 

that  it  might  be  necessary  to  excise  a  portion  of  the  first  rib  in  order  to 
expose  the  artery.  Two  strong  silk  ligatures  were  applied  to  the  artery  as  it 
emerged  from  the  chest,  and  the  vessel  was  divided  between  them.  The 
deltoid  muscle  was  cut  through  a  little  below  the  clavicle,  and  the  clavicle 
sawed  through  at  about  2.5  cm.  from  its  outer  end.  The  aneurism,  the 
greater  part  of  the  clavicle,  a  piece  of  the  deltoid  muscle  and  about  6  cm. 
of  the  subclavioaxillary  vein  were  then  removed  in  one  piece.  The  vein  was 
intimately  adherent  to  the  aneurism.  The  axillary  artery  was  ligated  at  the 
beginning  of  its  second  part.  The  operation  as  a  whole  was  a  tedious  one 
and  consumed  3-|  hours.  The  wound  was  closed  with  interrupted  buried 
skin  sutures  of  fine  black  silk.  The  large  dead  space  incompletely  covered 
by  the  skin  was  bridged  over  with  gutta-percha  tissue. 

"  May  23, 1892. — At  this,  the  second  dressing,  13  days  after  the  operation, 
it  may  be  observed  that  the  dead  space  is  almost  completely  filled  with  a  blood 
clot.  This  clot  has  not  broken  down  and  is  quite  throughout  replaced  by 
granulation  tissue.  The  patient  has  not  had  a  disturbing  symptom  since 
the  operation. 

"  The  left  arm  has  never  swelled  and  has  at  no  time  been  cold.  For  a 
few  days  only  there  was  a  slight  numbness  of  the  tips  of  the  fingers  and 
particularly  of  the  thumb.  The  case  was  altogether  a  most  fortunate  one 
for  operation  in  that,  thanks  to  the  clot  which  occupied  the  sac,  the  collateral 
circulation  had  already  been  well  established." 

In  a  recent  number  (January,  1920,  vol.  vii,  p.  390)  of  the  British 
Journal  of  Surgery  Mr.  L.  R.  Braithwaite/  of  Leeds,  recounts  interestingly 
his  quite  stirring  experiences  in  excising  an  aneurism,  about  the  size  of  a 
hen's  egg,  of  the  right  subclavian  artery.  This  is  the  fifth  case  of  which  I 
happen  to  know  of  excision  of  a  subclavian  aneurism,  Moynihan's  **  (1897) 
being  the  second,  Dunow's  "  the  third,  and  Duval's  "  the  fourth.  "With  these 
the  case  of  Schopf  n  might  be  perhaps  enumerated,  although  Schopf's  aneu- 
rism was  essentially  of  the  axillary  artery,  his  proximal  ligature  being  ap- 
plied from  below  the  clavicle. 

In  exposing  his  aneurism  Braithwaite  adopted  the  method  of  Moynihan, 
turning  down  in  a  flap  of  pectoral  muscle  a  central  piece  of  the  clavicle. 

The  operation  in  all  of  the  five  cases  was  successful,  but  Moynihan's 
patient,  who  survived  the  operation  of  this  brilliant  surgeon  58  days,  died 
on  the  59th  from  rupture  of  another  aneurism  proximal  to  the  one  excised. 

T.  E.  Schoipert.  (VI.)  Ligature  of  the  left  subclavian  in  its  first  por- 
tion for  aneurism  of  third  (Recovery).  Medical  Record,  New  York,  1898, 
vol.  liv,  p.  338. 

"Ligature  of  the  innominate  has  been  undertaken  in  all  21  times,  with 
one  recovery.*    The  right  subclavian  has  been  ligated  in  its  first  part  15 

*  The  innominate  artery  has  been  ligated  once  by  my  associate,  Dr.  Finney,  and 
four  times  by  myself  at  The  Johns  Hopkins  Hospital.  All  of  the  patients  recovered 
promptly.    (W.  S.  H.) 


524  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

times,  with  a  similar  result ;  the  left  subclavian  has  been  ligated  in  its  first 
part  only  twice,  once  by  Dr.  J.  Kearny  Rodgers,  of  New  York,  whose  patient 
died  of  secondary  haemorrhage  on  the  thirteenth  day.  The  second  case  is 
my  own,  which  I  am  about  to  report.* 

".  .  .  .  Wyeth  considers  the  operation  of  ligation  of  the  first  part  of  the 
left  subclavian  as  the  most  formidable  in  the  domain  of  operative  surgery. 
Sir  Astley  Cooper  f  failed  in  an  attempt  to  secure  the  vessel,  and  is  said  to 
have  wounded  the  thoracic  duct.  Jacobson,  in  his  '  Surgery/  writes :  '  It 
seems  most  doubtful  whether  the  improvement  in  modern  surgery  will  ever 
render  this  a  successful  operation;  however,  as  it  affords  good  practice  on 
the  dead  subject,  it  will  be  given/  Erichsen  considers  the  operation  as  bad 
in  principle  and  most  unfortunate  in  practice,  and  that  it  should  be  banished 
from  surgical  practice.  Bryant  says  ligature  of  the  subclavian  in  its  first 
part  on  the  left  is  scarcely  practicable,  and  Mulley  says  the  operation  is  quite 
out  of  the  question.  Treves  believes  that  no  artery  could  be  less  favorably 
placed  for  the  application  of  a  ligature,  and  in  like  unencouraging  manner 
treat  all  authorities  writing  on  this  subject.  Yet  in  the  face  of  these  words 
of  warning  emanating  from  the  brightest  stars  of  the  surgical  world,  when 
confronted  with  a  malady  so  universally  fatal,  we  are  prompted  to  summon 
courage  and  skill  and  attempt  what  has  heretofore  seemed  an  impossibility. 

"  A  negro  ....  J.  H.,  aged  56  years,  was  admitted  to  the  Shreveport 
Charity  Hospital  with  an  aneurism,  about  the  size  of  an  orange,  involving 
the  third  part  of  the  left  subclavian.  The  corresponding  shoulder  and  arm 
were  very  oedematous  and  supported  by  the  right  hand.  He  complained  of 
a  constant  great  weight  and  aching  of  the  parts;  that  he  never  had  one 
moment  of  relief.  He  stated  that  about  April  1st,  while  chopping  a  piece 
of  timber  overhead  with  a  heavy  axe,  suddenly  his  arm  gave  way  and  the  axe 
dropped  by  his  side.  After  he  had  rubbed  his  arm  for  a  moment  its  useful- 
ness was  restored  and  he  proceeded  with  his  work.  Shortly  after  this  a  small 
pulsating  tumor  was  noticed  in  the  supraclavicular  fossa,  which  obtained  the 

*"It  is  true,  however,  that  Dr.  Halsted  recently  successfully  ligated  this  vessel 
for  the  extirpation  of  a  tumor.  It  was  not  ligated  in  continuity  and  the  operation 
was  altogether  a  different  procedure  with  a  different  aim  in  view." 

t  The  aneurism  in  this  case  of  Sir  Astley  Cooper  was  below  the  clavicle  and  forced 
this  bone  upwards.  He  attempted  to  tie  the  subclavian  artery  external  to  the  scaleni 
muscles — not  in  its  first  portion. 

The  London  Medical  Review,  1809,  ii,  p.  300.  "  Medical  and  Surgical  Intelligence, 
Art  2.  In  a  case  of  subclavian  aneurism  which  lately  occurred  in  Guy's  Hospital,  Mr. 
A.  Cooper  attempted  to  tie  the  subclavian  artery  above  the  clavicle.  The  aneurism 
was  very  large,  and  the  clavicle  was  thrust  upward  by  the  tumour,  so  as  to  make  it 
impossible  to  pass  a  ligature  under  the  artery  without  incurring  the  risk  of  including 
some  of  the  nerves  of  the  axillary  plexus.  The  attempt  was  therefore  abandoned. 
This  artery  has  been  successfully  tied  below  the  clavicle  by  Mr.  Keate,  but  never  yet 
as  far  as  we  know,  above  that  bone." 

"Case  of  subclavian  aneurism,  which  occurred  in  Guy's  Hospital,  London;  com- 
municated to  Dr.  Miller,  by  Valentine  Mott,  M.  D.,  Corresponding  Member  of  the 
Medical  Society  of  London,  etc." 

The  Medical  Repository,  N.  Y.,  1810,  third  Hexade,  vol.  i,  p.  331.  (W.  S.  H.) 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  525 

size  of  an  orange  a  month  later  (March  7th),  when  I  operated My 

incision  was  begun  on  the  sternum,  two  inches  below  its  crest,  and  carried 
across  the  sternoclavicular  articulation  parallel  to  but  one-half  an  inch 
external  to  the  inner  border  of  the  sternomastoid  muscle,  the  entire  incision 
measuring  seven  and  one-fourth  inches.  I  then  divided  the  sternal  attach- 
ment of  the  sternocleidomastoid  muscle,  and  penetrated  the  deep  fascia  by- 
blunt  dissecting  with  flat  curved  scissors.  I  was  now  brought  in  contact 
with  the  internal  jugular  vein  and  actually  denuded  the  carotid  artery  of  its 
sheath  two  inches  in  an  attempt  to  go  between  it  and  the  vein,  but  at  last 
was  compelled  to  abandon  this  route  and  proceed  by  the  tracheal  side  to  the 
inner  edge  of  the  scalenus  anticus  muscle,  half  an  inch  above  the  first  rib. 
My  ringer  placed  at  the  bottom  of  the  wound  first  recognized  the  dorsal  ver- 
tebra, then  the  artery,  which  was  dissected  clean,  and  an  aneurism  needle, 
carrying  No.  8  braided  silk,  passed  beneath  it  from  the  inner  side.  The 
pulse  in  the  left  arm  was  now  taken  note  of  and  found  to  be  of  the  same 
character  as  when  the  operation  was  begun,  but  when  the  ligature  was 
tightened  it  ceased  entirely.  I  was  careful  to  see  that  no  twist  was  in  my 
ligature,  that  the  side  and  not  the  edge  lay  in  contact  with  the  vessel,  and. 
that  it  was  drawn  only  sufficiently  to  control  entirely  its  circulation.  A 
second  ligature  in  like  manner  was  placed  about  one-sixteenth  of  an  inch 
above.  The  broad  base  of  my  first  incision  rapidly  formed  itself  into  a  cone 
with  a  very  narrow  apex,  which  made  ligature  of  this  deep-seated  artery 
extremely  difficult.  During  the  operation  I  found  it  necessary  to  use  a  long- 
bladed  smooth  retractor  in  order  that  it  might  be  applied  deeply  in  the  wound 
and  press  away  the  jugular  vein  and  aneurismal  tumor,  which  was  almost 
in  contact  with  the  trachea. 

"  The  divided  segment  of  the  sternomastoid  muscle  was  brought  together 
with  catgut  and  the  wound  closed  with  catgut  and  dressed  with  iodoform 
collodion.  Primary  union  subsequently  followed  under  one  dressing.  It  was 
not  necessary  to  ligate  a  single  bleeding  point.  My  patient  made  an  unevent- 
ful recovery,  and  is  making  himself  generally  useful  about  the  hospital  in 
this,  the  ninth  week  after  operation.  The  oedema  of  his  arm,  shoulder  and 
hand  has  entirely  disappeared,  normal  function  being  about  restored,  but 
no  radial  pulse  is  yet  perceptible  in  the  left  arm."  * 

F.  Kammeker.  (VII.)  Ligature  of  the  first  portion  of  the  left  sub- 
clavian artery  for  aneurism;  death  after  four  weeks.  Medical  Record,  New 
York,  1899,  vol.  lvi,  p.  924. 

"  L.  "W.,  aged  47  years,  was  admitted  to  the  German  Hospital,  in  New 
York,  on  September  27,  1899.  Twenty  years  ago  he  had  contracted  syphilis, 
but  had  had  no  secondary  or  tertiary  lesions,  according  to  his  statement. 
In  July  of  this  year,  he  for  the  first  time  noticed  a  small  swelling  in  the  left 
supraclavicular  region.  He  distinctly  stated  that  he  had  received  a  blow  at 
this  point,  some  weeks  previous.  The  growth  gradually  increased  in  size 
until  he  came  to  the  hospital.  For  three  weeks  he  had  noticed  a  numbness 
in  the  third  and  fourth  fingers  of  the  left  hand.   When  I  first  saw  him,  a 

♦Was  the  aneurism  cured?    (W.  S.  H.) 


526  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

tumor  about  as  large  as  a  man's  fist,  was  present  in  the  region  above  stated. 
The  tumor  was  in  part  covered  by  the  sternal  end  of  both  the  left  sterno- 
mastoid  muscle  and  the  clavicle.  It  entirely  filled  the  angle  formed  by 
them,  and  overlapped  the  clavicle  to  a  slight  extent.  Immediately  above 
the  clavicle,  it  was  in  close  relation  and  adherent  to  the  skin  covering  it. 
The  pulse  at  the  radial  artery  was  scarcely  retarded  on  the  left  side.  Expan- 
sile pulsation  of  the  tumor  was  very  marked.  There  was  no  dullness  on  per- 
cussion of  the  anterior  upper  part  of  the  thorax. 

"  The  case  seemed  a  very  urgent  one  indeed,  more  especially  as  the  aneu- 
rism was  already  adherent  to  the  skin  above  the  clavicle  and  evidently 
preparing  to  rupture.  I  therefore  concluded  that  palliative  treatment  would 
be  of  little  value,  and  that  the  patient's  only  chance  lay  in  ligature  of  the 
subclavian  on  the  cardiac  side,  the  distal  ligature  being  unavailable  owing 
to  the  many  collateral  branches  of  the  sac.  I  was  encouraged  in  this  view 
by  the  belief  that  the  aneurism  did  not  extend  for  a  great  distance  into  the 
thorax,  and,  secondly,  by  a  perusal  of  Wyeth's  able  article  on  '  Special  Aneu- 
risms,' in  his  '  Text-Book  of  Surgery,'  where  the  author  gives  a  more  favor- 
able prognosis  of  ligature  of  the  left  than  of  the  right  subclavian  artery. 
He  bases  this  opinion  mainly  on  the  unfortunate  position  of  the  innominate 
artery,  which  is  in  a  direct  line  with  the  impact  of  the  blood  current  forced 
out  by  the  left  ventricle. 

"  Operation. — October  18,  1899.  Under  chloroform  a  transverse  incision 
passing  over  the  ends  of  both  clavicles  and  the  manubrium  of  the  sternum, 
fully  six  inches  in  length,  was  made.  A  vertical  incision  in  the  median  line 
of  the  body,  beginning  at  the  cricoid  cartilage  and  meeting  the  transverse 
incision  on  the  sternum,  was  now  added.  The  flaps  thus  outlined  were  dis- 
sected from  the  underlying  parts.  With  the  help  of  Gigli's  saw,  about  one 
and  a  half  inches  of  the  right  and  two  inches  of  the  left  clavicle,  bordering 
on  the  sternum,  were  resected.  The  aneurism  was  in  such  close  relation  to 
the  left  clavicle  that  great  care  had  to  be  taken  at  this  stage  of  the  operation. 
The  upper  end  of  the  sternum  was  now  removed  for  about  a  half  an  inch. 
The  two  innominate  veins  were  thus  exposed,  whereupon  it  became  apparent 
that  access  could  not  be  had  to  the  left  subclavian  artery,  owing  to  adhesions 
of  the  left  subclavian  vein  with  the  aneurism,  as  a  result  of  which  the  space 
between  the  first  left  rib  and  the  left  innominate  vein  was  entirely  too  small 
for  any  manipulations  at  such  depth  as  is  made  necessary  by  the  course  of 
the  subclavian  artery  after  its  origin  from  the  aortic  arch.  I,  therefore, 
resected  two  inches  of  the  sternal  end  of  the  first  rib,  and  removed  the 
corresponding  part  of  the  manubrium.  Even  now,  the  arch  formed  by  the 
superior  vena  cava  and  mainly  by  the  left  innominate  vein,  below  which,  of 
course,  I  had  to  search  for  the  subclavian  artery,  proved  a  great  hindrance, 
as  I  did  not  venture  to  dissect  the  innominate  vein  from  the  aneurismal  sac. 
Two  blunt  curved  retractors  were  inserted  below  the  venous  arch,  and  the 
latter  was,  with  great  care,  pulled  somewhat  in  an  upward  direction,  out  of 
harm's  way.  However,  during  the  entire  operation  I  was  in  continual  fear 
of  a  lesion  to  these  vessels,  as  at  times  strong  traction  had  to  be  exerted 
upon  them.  I  now  separated  the  tissues  to  the  left  of  the  three  arteries 
springing  from  the  arch  of  the  aorta,  with  my  fingers,  and  as  I  was  doing 
this  I  could  very  distinctly,  in  turn,  recognize  by  the  touch  first  the  innomi- 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  527 

nate,  then  the  left  carotid,  and  finally  the  left  subclavian  artery,  the  latter 
at  about  a  distance  of  two  and  a  half  inches  from  the  posterior  surface  of 
the  sternum.  When  pressure  was  exerted  upon  the  subclavian  with  the 
tip  of  my  finger,  forcing  it  toward  the  vertebral  column,  pulsation  immedi- 
ately ceased  in  the  aneurism  and  in  the  left  radial  artery.  Under  such  cir- 
cumstances, it  was  impossible  to  expose  the  subclavian  artery  to  view,  and 
then  to  separate  it  from  its  sheath.  To  accomplish  the  latter,  I  had  to  rely 
upon  the  sense  of  touch,  and  separation  of  the  artery  from  the  surrounding 
tissues  was  done  entirely  by  the  aid  of  my  left  index  finger  and  a  pair  of  long 
curved  scissors,  which  were  not  used  as  a  cutting  instrument.  Contrary  to 
my  expectations,  I  succeeded  in  this  very  well,  and  I  soon  had  the  vessel 
sufficiently  isolated  to  think  of  passing  a  ligature  around  it.  This  proved  a 
very  difficult  task,  however,  and  it  was  only  after  many  and  prolonged 
attempts  that  I  succeeded  in  passing  an  aneurism  needle  and  a  thread. 
With  the  assistance  of  the  latter,  I  also  passed  the  ligature  beneath  the 
artery.  It  consisted  of  several  pieces  of  chromicized  catgut,  wound  together. 
I  now  tightened  the  first  hitch  of  a  surgical  knot  until  I  felt  a  resistance, 
and  until  pulsation  in  the  aneurism  and  the  arteries  of  the  left  upper 
extremity  entirely  ceased,  my  object  being  to  stop  the  circulation,  but  not 
to  injure  the  coats  of  the  vessel.  The  knot  was  now  completed.  No  drainage 
was  established  from  the  seat  of  the  ligature,  but  the  soft  parts  were 
allowed  to  come  together,  closing  the  deep  wound  cavity.  The  vertical  inci- 
sion was  entirely  closed  by  sutures,  as  were  also  the  ends  of  the  horizontal 
incision,  thus  covering  what  remained  of  the  clavicles.  The  remainder  of 
the  wound  was  covered  with  loose  gauze.  The  operation  had  lasted  over 
three  hours. 

"  The  course  of  the  case  for  the  first  three  weeks  was  entirely  uneventful. 
After  the  first  few  days,  the  patient's  temperature  and  pulse  became  prac- 
tically normal,  and  the  wound  cavity  was  soon  lined  with  healthy  granula- 
tions and  filled  up  rapidly.  On  the  day  after  operation  there  was  no  pulse 
in  the  left  radial  nor  in  the  aneurism.  The  latter  had  decreased  considerably 
in  size.  The  left  arm  was  not  swollen,  nor  was  its  temperature  appreciably 
lowered,  and  sensation  and  muscular  power  were  intact.  On  the  following 
day,  October  20th,  there  was  faint  pulsation  at  the  left  radial,  but  none 
could  be  detected  in  the  aneurism,  and  sensation  in  the  arm  was  slightly 
retarded 

"  October  25th. — The  patient  complained  of  shooting  pains  in  the  left 

arm.    October  30th:    There  was  slight  oedema  of  the  left  hand 

November  6th :  On  that  day  the  patient  complained  of  a  feeling  of  weakness. 
Temperature,  101°  F. ;  pulse,  120.  On  removing  the  dressings,  it  was  seen 
that  they  were  saturated  with  a  considerable  quantity  of  fresh  blood.  Several 
clots  were  found  on  the  wound  surfaces,  which  otherwise  had  the  appear- 
ance of  healthy  granulations.  On  the  left  side,  near  the  aneurismal  sac, 
a  blood  clot  lay,  which  was  firmly  attached  to  the  surrounding  tissues. 

"  From  this  time  until  November  15th,  the  dressings,  which  were  changed 
at  least  once  a  day,  were  always  filled  with  blood,  although  when  they  were 
removed  no  bleeding  point  could  be  found  on  the  granulating  surface 

"  November  15th :  The  patient  showed  the  effect  of  the  continuous  loss 
of  blood  during  the  last  ten  days.  At  1  p.  m.  there  was  a  sudden  and  very 


528  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

severe  haemorrhage,  saturating  the  dressings  and  the  bed  linen 

There  was  slight  collapse,  but  he  rallied  well. 

"November  16th. — At  4  a.  m.   another  haemorrhage  occurred 

At  2.15  p.  m.,  death  from  exhaustion  took  place,  on  the  thirtieth  day  after 
operation. 

"Autopsy. — At  the  autopsy,  it  was  found  that  haemorrhages  had  been 
caused  by  rupture  of  the  artery  at  the  site  of  the  ligature.  The  wound  was 
in  an  aseptic  condition.  The  loop  of  chromicized  catgut  had  been  to  a  great 
extent  absorbed,  especially  at  the  point  immediately  opposite  the  knot,  but 
a  few  strands  were  still  present  here,  to  hold  the  loop  together.  The  latter 
had  cut  through  the  coats  of  the  artery  and  almost  completely  severed  the 
vessel;  but  it  was  still  lying  within  the  lumen.  The  knot,  however,  rested 
on  the  outside  of  the  vessel.  The  distance  from  the  aorta  to  the  ligature  was 
one  inch.  There  was  not  the  slightest  trace  of  a  clot  on  the  proximal  side  of 
the  ligature.  The  aneurismal  sac  was  lined  on  its  inner  surface  with  a 
layer  of  fibrin,  varying  from  one-half  an  inch  to  an  inch  in  thickness. 

"  The  left  subclavian  artery  has  to  my  knowledge  been  tied  twice  before 
in  its  portion  as  it  emerges  from  the  thorax,  once  by  Kearney  Rodgers  in 
1845  with  a  fatal  result,  and  once  by  Halsted  during  extirpation  of  an 
aneurism  as  a  preliminary  step.  His  patient  recovered.  In  my  own  case 
the  situation  of  the  aneurism  made  such  a  procedure  impossible  and  necessi- 
tated the  application  of  a  ligature  nearer  the  aortic  arch.  The  unfortunate 
final  result  after  an  undisturbed  course  for  several  weeks  was  rather  dis- 
couraging. I  had  used  an  absorbable  ligature,  and  the  wound  surfaces  had 
closed  around  the  same  without  suppuration — two  requisites  for  a  favorable 
result  after  deligation  of  large  arteries.  Whether  or  not  I  avoided  rupturing 
the  inner  coats  of  the  artery  while  tightening  the  first  hitch  of  the  surgical 
knot,  I  cannot  say — a  very  important  point,  according  to  the  experiments 
of  Ballance  and  Edmunds,  Senn,  and  others.  '  The  living  and  uninjured 
wall  is  the  only  true  safeguard  against  haemorrhage.'  *  to  quote  Ballance 
and  Edmunds,8  and  this  must  be  especially  true  of  the  first  portion  of  the 
subclavian  in  man,  as  the  walls  of  this  artery  are  exceptionally  thin  in  pro- 
portion to  its  size.  The  clot  on  either  side  of  the  ligature  has  really  little 
to  do  with  the  tissue  transformation  that  occurs  within  the  uninjured  vessel 
and  about  the  aseptic  ligature,  leading  to  permanent  occlusion  of  the  artery. 
Some  authors  (Bruns)  even  believe  that  when  the  coats  are  not  ruptured 
clotting  does  not  occur.  In  my  case  there  was  no  trace  of  a  clot  on  the 
proximal  side  of  the  ligature,  but  I  cannot  accept  this  as  a  proof  of  my  not 
having  injured  the  coats  during  the  application  of  the  ligature.  Senn's 
plan  of  applying  two  ligatures,  at  some  distance  from  each  other,  thus 
leaving  a  bloodless  space  between  them,  was  not  applicable  to  my  case.  Nor 
did  I  feel  that  I  could  have  applied  a  stayknot,  as  Ballance  and  Edmunds 
recommend,  with  any  amount  of  exactness,  owing  to  the  depth  of  the 
wound.  Still  it  seems  to  me  now  that  an  attempt  should  always  be  made, 
in  ligating  large  arteries,  to  pass  several  ligatures.    We  will  thus  most 

*  I  cannot  endorse  this  statement  of  Ballance  and  Edmunds,  Senn,  and  others,  for, 
in  my  opinion,  the  force  required  to  occlude  the  artery  necessarily  causes  necrosis  of  its 
wall  at  the  site  of  the  ligature.    (W.  S.  H.) 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  529 

readily  avoid  injury  to  the  coats  of  large  vessels  and  succeed  in  arresting 
the  circulation." 

To  Kammerer  belongs  the  credit  of  having  been  the  second  to  ligate  the 
left  subclavian  artery  within  the  thorax,  Bardenheuer  (1886)  being  the 
first.  The  operation,  courageously  and  cautiously  performed,  was,  for  its 
time,  a  surgical  feat  of  the  first  magnitude.  The  leak  in  the  artery  at  the 
site  of  the  ligature  probably  began  not  later  than  the  seventh  day  after 
operation,  when  the  patient  first  complained  of  shooting  pains  in  the  left 
arm,  although  there  was  no  external  indication  of  haemorrhage  until  on 
the  eighteenth  day  the  dressings  were  removed.  This  is  the  story  of  a  liga- 
ture in  an  aseptic  wound  cutting  its  way  through  an  artery.  At  the  autopsy 
it  was  found  that  all  but  a  few  of  the  strands  of  the  catgut  had  been  absorbed ; 
thus,  the  ligature  had  been  reduced  to  a  size  dangerously  small.  The  cause 
of  the  fatal  result  was  probably  either  the  fineness  of  the  remaining  strands 
of  the  ligature  or  an  incomplete  occlusion  of  the  artery  due  to  absorption 
of  the  catgut  or  to  the  slipping  of  the  knot. 

Dr.  Kammerer  felt  that  "the  unfortunate  result  after  an  undisturbed 
course  for  several  weeks  was  rather  discouraging."  It  would  indeed  be  dis- 
couraging were  we  not  in  a  position  to  profit  by  the  lesson  which  it  and 
similar  cases  have  taught.  Let  the  surgeon  who  is  about  to  ligate  a  large 
artery  bear  in  mind  the  following  facts : 

1.  Fine  ligatures  cut  through  the  arterial  wall  more  rapidly  than  coarse 
ones. 

2.  Partially  occluding  ligatures  and  crushing  ligatures  are  dangerous. 

3.  Absorbable  ligatures  may  disintegrate  unevenly,  and  thus  a  coarse 
ligature  be  reduced  to  a  fine  one;  or  the  knot  may  slip  and  thus  convert 
a  total  into  a  partial  occlusion. 

4.  Intimal  surfaces  brought  in  contact  cannot  unite  because  the  wall  of 
the  artery  becomes  necrotic  under  the  coarcting  ligature. 

5.  The  necrosed  wall  under  ideal  conditions  becomes  converted  into 
fibrous  tissue,  into  a  solid  cord  by  the  in-growth  of  blood  vessels  from 
the  ends. 

6.  Under  certain  conditions,  for  example  when  the  lumen  has  not  been 
totally  occluded,  or  the  wall  of  the  artery  has  been  too  severely  crushed, 
haemorrhage  may  be  prevented  by  the  formation  of  a  fibrous  tissue  capsule 
enveloping  the  ligature  and  the  arterial  defect.  Moderately  coarse  ligatures 
may,  without  causing  leakage  of  blood,  cut  their  way  through  an  artery 
ligated  in  continuity.  In  the  wake  of  such  a  slowly  cutting  ligature,  a 
partially  obturating  diaphragm  is  likely  to  form.  There  may  be  several 
crescentic-like  diaphragms,  their  free  concave  edges  bounding  the  lumen 
which  remains. 


530  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

7.  A  coarser  ligature  should  be  used  in  tying  an  artery  in  continuity  than 
for  occluding  the  ends  of  a  divided  one. 

8.  It  is  probably  safer,  when  feasible,  to  divide  an  artery,  tying  off  the 
ends,  than  to  ligate  it  in  continuity. 

9.  Catgut  ligatures  should  not  be  employed,  lest  some  strands  be  absorbed 
or  loosened  before  the  others,  and  it  is  probably  inadvisable  to  tie  with  a 
bundle  of  threads  of  any  kind.  It  is  decidedly  risky  to  apply — as  has  been 
recommended  and  practised — a  partially  coarcting  ligature  central  to  the 
totally  occluding  one,  for  the  arterial  wall  eventually  giving  way  as  it  must 
under  the  former,  it  is  only  by  the  formation  of  an  enveloping  fibrous 
tissue  capsule  or  by  repair  in  the  wake  of  the  cutting  thread  that  fatal 
haemorrhage  is  prevented.  For  the  ligation  in  continuity  of  large  arteries 
I  have  been  using  narrow  tape. 

10.  The  wound  should  be  closed  without  drainage,  and  completely. 

11.  If  infected,  the  wound  should  be  promptly  and  freely  opened  and 
treated  by  the  Carrel  method  with  an  antiseptic  solution  which  will  not 
endanger  the  devitalized  wall  of  the  artery  under  the  ligature. 

Dr.  Juxgst  (Saarbriicken).  (VIII.)  Ein  geheilter  Fall  von  Unter- 
bindung  der  Arteria  subchvia  sinistra  am  Aortenbogen.  Beitrage  z.  VI in. 
Chirurgie,  Tubingen,  1902,  Bd.  xxxiv,  p.  307. 

"  Although  the  following  case  has  already  been  published  as  a  dissertation 
by  my  one-time  assistant,  Dr.  Philipp,4i  yet  I  may  be  permitted  to  com- 
municate it  again  as  a  statistical  contribution,  since  it  would  appear  that 
up  to  this  time  it  is  the  first  case  of  ligation  of  the  subclavian  artery  at  the 
arch  of  the  aorta  which  has  resulted  in  cure,  and  since  it  may  be  difficult 
to  obtain  access  to  Dr.  Philipp's  dissertation. 

"  The  patient,  female,  aet.  35,  was  shot  in  the  left  side  of  the  neck  on 
the  night  of  June  12-13.  1899,  the  shot  entering  in  front,  and  passing  out- 
wards and  upwards.  The  injury  was  followed  by  severe  bleeding,  which 
ceased  of  itself,  and  the  next  morning  the  patient  was  sent  to  the  Burger- 
hospital  of  Saarbriicken. 

"  We  find  a  poorly  nourished,  moderately  anaemic  woman.  The  skin  in 
the  left  supraclavicular  region  is  sprinkled  with  a  large  number  of  black 
grains  of  gunpowder,  is  red,  inflamed  and  swollen,  and  the  skin  of  the  whole 
left  side  of  the  neck,  shoulder  and  upper  thorax  almost  to  the  other  side  of 
the  chest  is  purple.  About  2  cm.  from  the  sternal  end  of  the  left  clavicle, 
close  to  its  upper  edge,  there  is  a  pea-sized  entrance  wound  with  ragged 
burnt  edges  from  which  only  very  little  watery  blood  can  be  pressed  out. 
There  is  no  exit  wound.  The  whole  supraclavicular  region  is  filled  with  a 
hard-soft  swelling,  in  which  there  is  neither  pulsation  nor  bruit.  The  radial 
and  ulnar  pulses  are  unchanged  and  on  both  sides  are  equal  in  strength; 
there  is  no  perceptible  difference  in  the  height  of  the  pulse  wave.  There 
are  sharp  shooting  pains  in  the  left  shoulder,  radiating  towards  the  arm. 
The  left  upper  arm  is  quite  a  little  swollen :  there  is  complete  motor  paraly- 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  531 

sis  of  the  whole  arm,  passive  movements  are  very  painful.  The  sensation 
of  the  skin  to  touch,  temperature  and  pain  is  much  diminished — in  places 
entirely  absent.    There  are  no  pulmonary  symptoms. 

"  The  presence  of  a  large  haematoma  in  the  left  supraclavicular  fossa, 
considered  in  its  relation  to  the  serious  haemorrhage  which  followed  the 
gunshot  wound,  made  it  probable  that  a  large  vessel  had  been  injured, 
although  at  the  outset  the  subclavian  artery  seemed  not  to  be  involved,  for 
the  pulse  in  the  left  arm  was  normal,  and  no  abnormal  sounds  were  to  be 
heard  at  the  site  of  the  wound.  The  complete  motor  paralysis  had  to  be 
regarded,  in  part  at  least,  as  due  to  compression  of  the  plexus  by  the  out- 
poured blood,  for  it  was  unbelievable  that  a  single  bullet  could  have  injured 
all  the  roots  of  the  plexus,  which  at  this  point  lie  so  far  apart.  The  treat- 
ment for  the  moment  had  to  abide  the  issue,  for  haemorrhage  had  ceased 
and  closure  of  the  involved  artery  seemed  probable.  Under  bandages  of 
acetated  white  clay  the  signs  of  inflammation  subsided  and  movement  of 
the  first  three  fingers  and  sensation  in  the  radial  area  improved;  only  in 
the  ulnar  region  did  paralysis  and  anaesthesia  persist.  The  general  condi- 
tion was  good. 

"  Suddenly,  in  the  night  of  June  20-21,  after  the  woman  had  complained 
the  whole  previous  day  of  not  feeling  well,  a  haemorrhage  occurred  which 
was  slight  and  of  short  duration,  and  which  was  controlled  by  a  compressive 
bandage  and  ice.  But  the  next  day  the  condition  was  quite  changed;  the 
swelling  in  the  left  supraclavicular  region  had  become  much  larger  and 
showed  distinct  pulsation,  the  radial  and  ulnar  pulses  were  barely  palpable, 
motilitv  and  sensation  were  becoming  less ;  but  still  no  bruit  was  heard  and 
no  thrill  felt. 

"  There  can  be  no  doubt  now  that  in  spite  of  the  absence  of  symptoms 
at  the  beginning  we  are  confronted  with  a  wound  of  the  subclavian  artery, 
since  the  haemorrhage  from  one  of  the  smaller  arteries  of  this  region  would 
not  cause  pulsation  of  this  sort  in  the  haematoma  or  an  almost  complete 
suppression  of  the  peripheral  arterial  pulse.  Taking  into  consideration  the 
topographical  situation,  this  wound  of  the  artery  must  in  all  probability  lie 
in  the  neighborhood  of  the  cleft  between  the  scaleni  muscles,  and  therefore 
the  ligation  would  be  unusually  difficult  and  fraught  with  danger.  For 
this  reason  an  attempt  was  first  made  to  produce  thrombosis  of  the  haema- 
toma with  injections  of  thinned  chloride  of  iron  (Liquor  Piazza) — without 
result,  it  is  true,  because  the  injections  were  very  painful  and  had  to  be 
discontinued  as  they  excited  the  already  nervous  and  over-sensitive  woman. 
Since,  in  spite  of  ice  and  compressive  bandages,  smaller  secondary  haemor- 
rhages frequently  occurred  (June  30th,  July  6th,  12th,  14th,  19th),  and 
on  July  19th  the  radial  pulse,  which  up  to  this  time  had  been  weakly  pal- 
pable, entirely  disappeared,  the  resolution  to  ligate  had  to  be  made  and 
carried  out.  But  meanwhile  the  topographical  conditions  had  been  made 
much  more  difficult  by  the  oft  recurring  haemorrhages :  there  was  a  haema- 
toma almost  the  size  of  a  man's  fist,  which  could  be  followed  deep  into  the 
soft  parts  of  the  neck  and  had  thinned  the  skin  almost  to  perforation. 

"  On  July  21,  1899,  under  chloroform  narcosis,  an  incision,  10  cm.  long, 
was  made  outwards  from  the  insertion  of  the  sternomastoid  along  the  upper 
border  of  the  clavicle,  and  one  of  the  same  length  upwards  along  the  lateral 


532  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

border  of  the  muscle.  The  acute-angled  skin  flap  was  dissected  up,  where- 
upon the  muscle,  lying  like  a  smooth  band  on  the  tumor,  was  cut  through 
below.  On  the  clavicle,  corresponding  to  the  entrance  wound,  was  found  a 
shallow  groove  and  in  it  a  small  detached  bit  of  lead,  which  had  evidently- 
glanced  off  from  the  shot.  Now  beneath  the  fascia  lay  a  thick  black  coagu- 
lum ;  this  was  being  carefully  removed  towards  the  depths  of  the  neck,  when 
suddenly  a  great  thick  stream  of  blood  gushed  out  of  the  wound.  Happily 
we  succeeded,  by  digital  compression  towards  the  depths,  in  suppressing 
further  haemorrhage,  although  it  was  not  possible  to  reach  the  bleeding 
point;  first  because  it  lay  too  deep,  and  further  because  the  approach  was 
covered  by  the  compressing  hand.  Both  angle  incisions  were  so  lengthened 
over  the  summit  that  the  horizontal  portion  reached  to  the  right  sterno- 
clavicular articulation,  the  oblique  one  as  far  as  the  second  left  rib:  and 
now  the  sternal  third  of  the  left  clavicle  and  the  whole  manubrium  sterni 
were  resected.  Although  the  cervical  aperture  to  the  thorax  was  now  opened, 
we  did  not  succeed  in  identifying  with  certainty  the  subclavian  artery  at 
the  inner  side  of  the  scaleni,  because  orientation  was  made  very  difficult  on 
account  of  the  indurated  mass  which  had  formed  around  the  large  haema- 
toma.  Therefore,  one  had  first  of  all  to  locate  the  left  carotid;  by  tracing 
this  downwards,  we  were  enabled  to  reach  the  arch  of  the  aorta  and  there 
to  expose  the  subclavian  artery  and  ligate  it  with  a  silk  ligature  about  1.5 
to  2  cm.  from  its  origin.  Now,  after  removal  of  the  compressing  finger  the 
bleeding  ceased,  and  we  were  proceeding  with  the  evacuation  of  the  coagula 
from  the  large  cavity,  when  suddenly  again  a  rather  severe  haemorrhage 
occurred,  which  was  again  controlled  at  the  same  spot  by  digital  compres- 
sion. By  careful  evacuation  of  the  peripheral  part  of  the  cavity  the  sub- 
clavian artery  was  now  discovered  and.  followed  centrally  as  far  as  the  finger 
compressing  it  on  the  first  rib,  and  here  was  found  a  longitudinal  slit  3  mm. 
long,  with  sharp  edges,  on  the  upper  part  of  the  artery  precisely  at  the  point 
where  it  emerges  from  between  the  scaleni  muscles.  As  it  appeared  quite 
certain  that  this  subsequent  haemorrhage  must  have  been  a  retrograde  one 
from  the  left  vertebral  artery,  the  subclavian  was  once  more  ligated  periph- 
eral and  central  to  its  wound.  Bleeding  now  finally  ceased  and  the  entire 
large  wound  cavity  was  stuffed  with  strips  of  iodoform  gauze,  which  were 
also  carried  as  far  as  the  arch  of  the  aorta,  without,  however,  coming  directly 
into  contact  with  the  point  of  ligature.  The  cavity  was  reduced  in  size  by 
some  stitches  from  the  clavicle  to  the  sternomastoid. 

"  The  course  for  the  first  few  days  was  rather  stormy,  and  quite  marked 
collapse  made  repeated  infusions  of  salt  and  injections  of  ether  necessary. 
July  26th  the  temperature  rose  to  39.1°  and  quite  a  large  quantity  of  milky 
fluid  came  from  the  dressing,  necessitating  frequent  renewals  of  the  super- 
ficial bandages,  and  the  removal  on  July  28th  of  part  of  the  iodoform  gauze, 
whereupon  the  temperature  gradually  sank.  The  constant  moistening  with 
the  milky  secretion  produced  a  maceration  of  the  neck  and  back,  which 
required  special  attention  in  order  to  prevent  decubitus  and  eczema.  This 
flow  gradually  diminished  and  ceased  entirely  August  6th.  While  the  flow 
of  chyle  continued  there  was  very  marked  thirst,  which  gradually  disap- 
peared as  the  leakage  diminished.  At  each  change  of  dressing  all  the  loosened 
iodoform  gauze  was  cut  away,  the  last  piece  being  removed  August  6th. 
During  the  final  days  the  wound  and  the  dressings  had  a  decidedly  fetid 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTEEY  533 

odor,  evidently  due  to  the  putrefaction  of  the  remains  of  the  chyle  in  the 
tampons,  but  the  temperature  was  normal,  and  the  wound  was  granulating 
satisfactorily. 

"  On  the  first  day  after  the  operation  the  weakness  was  so  great  that  the 
patient  could  not  speak  aloud.  As  the  condition  improved  the  peculiar 
rough  sound  of  her  voice  was  striking  and  made  one  suspicious  of  one- 
sided paralysis  of  the  vocal  cord.  It  was  later  found  by  laryngoscopic 
examination  that  there  was  a  complete  paralysis  of  the  left  recurrent  nerve ; 

this  was  still  present  when  the  patient  was  discharged The  radial 

and  ulnar  pulses  did  not  reappear.  Motility  in  the  upper  arm  was  regained 
very  soon,  in  the  forearm  and  hand  only  gradually.  The  wound  healed  slowly 
per  secundum  and  was  closed  by  the  middle  of  October. 

"  The  patient  remained  in  the  hospital  until  her  recovery,  and  the  left 
arm  was  treated  with  massage  and  electricity  until  December  2,  1899,  when 
she  was  discharged  with  the  following  findings :  Wound  healed  with  a  broad 
scar,  left  side  of  the  neck  sunken  in  on  account  of  the  absence  of  the  cord 
of  the  sternomastoid.  At  the  place  of  resection  of  the  bones  of  the  clavicle 
and  manubrium  sterni  there  are  firm  periosteal  bone  formations.  Left  arm 
can  be  moved  in  the  shoulder-joint,  but  cannot  be  raised.  The  left  hand  can 
be  lifted  to  the  mouth,  but  cannot  make  a  fist;  fingers  only  very  slightly 
movable,  actively  or  passively.  In  the  ulnar  region  sensibility  of  all  qualities 
extinct;  no  striking  atrophic  changes.  Complete  left-sided  paralysis  of  the 
recurrent  nerve,  voice  loud  and  rough. 

"  In  the  foregoing  case  the  cure  was  effected  by  ligation  of  the  subclavian 
artery  in  its  first  portion.  At  the  time  of  the  publication  of  the  dissertation, 
Dr.  Philipp  could  not  discover  a  case  which  had  been  cured  by  this  ligation ; 
all  of  the  18  *  cases  collected  by  him  died  very  soon  after  the  operation, 
which,  as  far  as  could  be  ascertained,  had  been  undertaken  only  three  times 
on  the  left  side.  I  have  searched  the  literature  since  that  time  and  have  not 
been  able  to  find  another  cured  case.  My  case  may  first  of  all  prove  that, 
under  favorable  conditions,  a  cure  following  this  ligation  is  possible,  and 
that  the  prognosis  is  not  so  absolutely  bad  that  in  a  similar  case  one  should 
not  at  least  undertake  the  operation.  Further,  my  case  confirms  what  has 
been  emphasized  by  all  observers,  the  difficulty  of  diagnosis,  which  in  this 
case  was  greatly  increased  because  there  was  no  real  division  of  the  artery, 
but  only  a  lateral  wound,  which  caused  the  symptoms  of  a  severe  wound  to 
make  their  appearance  gradually. 

"  The  technical  difficulties  are  naturally  much  greater  on  the  left  side 
than  on  the  right  and  necessitate  free  exposure  of  the  field  of  operation  by 
the  resection  of  a  portion  of  the  clavicle  and  of  the  manubrium  sterni, 
whereby  alone  it  is  possible  to  orient  oneself  and  to  secure  freedom  of 
action.  The  wounding  of  the  thoracic  duct  and  of  the  recurrent  nerve 
(or  the  vagus  trunk?),  which  occurred  in  my  case,  are  technical  faults, 
which  are  certainly  to  be  avoided  and  may  be  excused  by  the  haste  with 
which  I  was  obliged  to  operate  since  the  compressing  finger  of  the  assistant 
was  becoming  tired  and  had  to  be  supported  by  the  finger  of  still  another 

*  Philipp's  collection  includes  the  ligations  of  the  first  portion  of  the  right  as  well 
as  of  the  left  subclavian.   (W.  S.  H.) 


534  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

assistant.    That  the  wounding  of  the  thoracic  duct  does  not  always  have 
serious  consequences  is  also  proved." 

The  first  step  in  the  operation  of  Dr.  Jungst  should,  in  my  opinion,  have 
been  the  exposure  and  provisional  occlusion  of  the  thoracic  portion  of  the 
subclavian.  Had  this  been  done  the  patient  would  have  been  spared  the 
major  part  of  the  loss  of  blood.  The  evidence  is  insufficient  to  sustain  the 
contention  that  the  ultimate  haemorrhage  was  altogether  a  retrograde  one 
from  the  vertebral  artery.  I  shudder  to  fancy  what  the  result  might  have 
been  in  our  second  case  (No.  XXI)  had  I  proceeded  after  the  manner  of 
Jungst.  To  stuff  the  wound  with  gauze  was  also  an  error ;  the  wound  should, 
I  think,  have  been  closed  without  drainage,  absolute  haemostasis  having, 
of  course,  been  attained. 

Charles  Stonham.  (IX.)  "Westminster  Hospital.  A  case  of  aneu- 
rism of  the  second  and  third  parts  of  the  left  subclavian  artery;  ligature  of 
the  first  part;  recurrent  pulsation;  simultaneous  ligature  of  the  inferior 
thyroid,  vertebral,  and  third  part  of  the  axillary  arteries;  recovery."  Lancet, 
London,  1902,  vol.  ii,  p.  291. 

"  A  man,  aged  43  years,  was  admitted  into  Westminster  Hospital  on 
April  13,  1899,  in  consequence  of  a  swelling  '  in  the  root  of  the  neck  on  the 
left  side/  The  patient  had  contracted  syphilis  14  years  previously  and 
10  months  before  admission  he  had  a  gumma  on  the  left  calf,  one  on  the 
inner  side  of  the  left  thigh,  and  a  third  on  the  left  forearm.  In  November, 
1895,  he  was  admitted  into  St.  Peter's  Hospital,  Bristol,  in  consequence  of 
'  bronchitis  and  considerable  haemoptysis  ' ;  he  was  an  in-patient  10  months, 
when  he  was  discharged  as  suffering  from  phthisis  and  being  incurable.  He 
was  then  admitted  into  the  St.  George's  Infirmary,  Fulham-road,  and  im- 
proved considerably.  On  his  discharge  he  resumed  his  work  as  a  carpenter 
and  worked  regularly  until  he  came  to  the  hospital,  although  he  was  '  troubled 
with  his  chest  and  a  cough.'  He  had  also  suffered  from  piles  and  right- 
sided  sciatica.  As  regards  his  present  illness,  five  months  before  admission 
the  patient  experienced  an  aching  pain  in  the  upper  part  of  the  left  chest 
and  noticed  a  swelling  of  about  the  size  of  a  walnut  at  the  root  of  the  neck 
above  the  left  clavicle.  This  swelling  was  at  first  very  tender,  but  the  pain 
soon  passed  off  and  the  patient  put  pressure  on  the  swelling  for  two  or  three 
days,  after  which,  according  to  him,  it  disappeared,  but  suddenly  reappeared 
two  or  three  days  later.  This  swelling  gradually  increased  in  size,  but 
although  at  first  he  occasionally  suffered  acute  stabbing  pain  in  the  left 
chest  and  down  the  left  arm  this  did  not  trouble  him  latterly  and  he  con- 
tinued his  work  until  April  12,  1899,  the  day  before  his  admission. 

"  On  April  17th  the  patient  was  thin  and  had  a  worn  expression.  The 
chest  was  badly  formed  and  its  mobility  was  markedly  deficient.  The  per- 
cussion note  was  somewhat  impaired  at  the  apex  on  both  sides;  there  were 
no  moist  sounds  or  other  abnormality;  there  was  no  expectoration.  The 
heart  was  normal.    The  arteries  were  not  rigid  or  particularly  tortuous. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  535 

....  The  ends  of  the  fingers  were  clubbed,  especially  on  the  left  hand. 
There  was  a  swelling  in  the  left  supraclavicular  region  of  about  the  size  of 
a  duck's  egg  rising  well  above  the  clavicle  and  situated  over  the  third  and 
part  of  the  second  part  of  the  subclavian  artery,  extending  forwards  beneath 
the  clavicular  head  of  the  sternomastoid  to  near  the  middle  of  the  sternal 
head.  The  swelling  occupied  the  whole  of  the  supraclavicular  fossa,  but 
there  was  no  dullness  below  the  clavicle  indicative  of  its  extension  in  that 
direction,  although  it  is  true  that  there  was  deficient  resonance  at  the  apex 
of  both  lungs;  this  deficiency  was  equal  on  both  sides.  The  swelling  was 
expansile  and  there  was  a  very  distinct  systolic  bruit  and  thrill.  The  diag- 
nosis was  aneurysm  affecting  the  convexity  of  the  second  and  third  parts 

of  the  left  subclavian  artery After  carefully  considering  this  case  in 

all  its  bearings  and  being  convinced  that  rupture  of  the  sac  would  occur  in  a 
short  time,  Mr.  Stonham  determined  to  attempt  cure  by  proximal  ligature 
in  spite  of  the  general  opinion  that  such  an  operation  should  not  be 
undertaken. 

"  Operation,  April  26, 1899. — An  operation  was  performed  on  April  26th. 
The  patient  was  placed  under  chloroform  and  Mr.  Stonham  proceeded  to 
tie  the  vessel  in  the  thorax,  being  most  ably  assisted  by  Mr.  E.  P.  Paton. 
The  shoulders  being  somewhat  raised  by  pillows,  the  head  thrown  slightly 
backwards,  and  the  face  turned  to  the  opposite  side,  a  vertical  incision  about 
six  inches  long  was  made  parallel  to,  and  just  outside,  the  sternal  head  of 
the  sternomastoid,  the  centre  of  the  incision  being  placed  over  the  sterno- 
clavicular articulation.  The  upper  part  of  this  incision  exposed  the  mus- 
cular fibres  while  the  lower  half  was  made  right  down  to  the  sternum. 
A  second  incision  was  then  made  along  the  inner  half  of  the  clavicle,  the 
knife  being  made  to  cut  down  to  the  bone.  The  clavicular  head  of  the 
sternomastoid  was  separated  from  its  attachment,  the  clavicle  being  closely 
'  hugged '  all  the  time ;  this  part  of  the  muscle  with  the  upper  triangular 
flap  of  skin  was  very  carefully  turned  upwards  and  outwards.  A  small  por- 
tion of  the  pectoralis  major  was  now  separated  from  the  sternum  and  clavicle 
and  was  turned  with  the  second  triangular  portion  of  skin  downwards  and 
outwards.  The  parts  were  very  vascular  but  no  vessel  of  any  importance 
was  encountered ;  all  bleeding  points  were  at  once  clamped  and  tied,  the  most 
troublesome  one  being  a  small  perforating  branch  in  the  first  intercostal 
space.  The  clavicle  was  now  very  carefully  sawn  about  one  inch,  or  rather 
more,  from  its  sternal  end,  the  division  being  completed  with  bone  forceps ; 
the  sternal  portion  of  the  bone  was  isolated  by  means  of  a  raspatory  and  by 
the  knife,  both  instruments  being  kept  as  close  as  possible  to  the  bone  so  that 
in  point  of  fact  the  resection  was  practically  subperiosteal.  During  the  divi- 
sion of  the  bone  the  deeper  parts  were  protected  by  a  retractor.  The  floor 
of  the  wound  was  now  seen  to  consist  of  a  portion  of  the  clavicular  perios- 
teum, a  layer  of  the  deep  cervical  fascia  and  muscular  tissue.  By  means  of 
two  pairs  of  dissecting  forceps  the  outer  edge  of  the  muscular  layer  was 
clearly  defined,  the  muscles  being  the  sternohyoid  and  the  sternothyroid: 
these  were  drawn  inwards.  Further  blunt  dissection  revealed  the  carotid 
artery  running  vertically  upwards  along  the  inner  border  of  the  wound 
which  was  now  becoming  very  deep.  On  the  outer  side  and  below  was  the 
dome  of  the  pleura  covered  by  the  junction  of  the  subclavian  and  internal 
jugular  veins  and  a  short  piece  of  the  left  innominate.    These  veins  were 


536  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

carefully  drawn  downwards  and  outwards,  when  deeply  behind  them  about 
two  thirds  of  an  inch  of  the  subclavian  artery  were  revealed,  surrounded  by 
a  little  loose  fat.  The  thoracic  duct  was  not  seen  nor  were  any  nerves  or 
veins  other  than  those  mentioned.  Little  difficulty  was  experienced  in  pass- 
ing an  ordinary  aneurysm  needle  armed  with  salicylic  floss  silk  round  the 
vessel  from  within  outwards;  the  finger  was  then  placed  upon  the  vessel 
(which  was  apparently  quite  healthy  and  highly  elastic)  and  the  loop  of 
the  ligature  drawn  tight  beneath  it,  the  radial  pulse  and  all  pulsation  in 
the  aneurysmal  sac  were  arrested,  and  the  ligature  was  then  tied  with  a 
surgeon's  knot,  the  ends  being  cut  quite  short.  The  ligature  was  only  tied 
with  sufficient  force  to  occlude  the  artery,  not  to  rupture  the  inner  coats; 
it  was  situated  behind  the  sternoclavicular  joint  about  half  an  inch  from 
the  aneurysmal  sac.  The  deep  wound  was  carefully  dried  and  the  displaced 
structures  were  allowed  to  resume  their  normal  position,  the  sternohyoid 
and  sternothyroid  muscles  completely  hiding  the  artery  from  view.  The 
skin  wound  was  closed  with  silk-worm  gut  and  horsehair  interrupted  sutures, 
a  short  gauze  drain  being  placed  in  the  middle  of  the  incision  as  deep  as 
the  sternohyoid  and  thyroid  muscles.  The  wound  was  dressed  with  double 
cyanide  gauze  and  salicylic  wool,  the  left  arm,  covered  in  Gamgee  tissue,  was 
bandaged  to  the  side,  and  one-third  of  a  grain  of  morphia  was  administered 

hypodermically 

"  On  April  27th  ....  he  had  slept  for  six  hours  and  had  been  com- 
fortable. The  pulse  was  84,  regular,  and  of  rather  low  tension.  The  tem- 
perature was  normal.  One  of  the  fingers  when  examined  was  quite  warm 
and  the  circulation  was  good.  There  was  no  pain.  The  pulse  was  76.  The 
circulation  in  the  left  hand  was  good  and  the  radial  pulse  distinct.  He  com- 
plained a  good  deal  of  thirst On  May  2d  the  wound  was  dressed  and 

the  gauze  drain  was  removed.  Slight  pulsation,  not  expansile,  was  felt  in 
the  sac,  which  was  much  smaller  and  harder.  On  the  9th  the  stitches  were 
removed ;  the  wound  was  soundly  healed ;  it  was  now  covered  with  a  collodion 
dressing.  The  sac  was  smaller,  denser,  and  more  localised;  slight  pulsation 
could  be  felt  in  it,  but  could  not  be  seen.   The  radial  pulse  was  more  distinct. 

From  May  9th  to  June  2d  the  patient  was  kept  quiet  in  bed On  the 

latter  date  the  pulsation  in  the  sac  was  distinctly  excentric  and  the  sac  had 
somewhat  increased  in  size  in  the  outward  direction.  Until  a  week  before 
June  21st  this  increased  size  of  the  sac  slightly  diminished,  but  now  the 
pulsation  was  more  evident,  especially  at  the  upper  and  outer  part.  The 
patient  also  complained  of  pain  in  the  shoulder  and  down  the  upper  arm. 
The  radial  pulse  was  very  good  but  delayed  in  time*  On  the  22d  equable 
and  continuous  pressure  was  applied  to  the  sac  by  means  of  marine  sponges 
and  bandages.  On  the  24th  there  was  no  result  from  the  pressure  and  it  was 
consequently  discontinued;  indeed,  the  sac  was  clearly  increasing  outwards 
and  upwards  and  the  pulsation  was  becoming  more  evident.  Dr.  Allchin 
kindly  saw  the  case  with  Mr.  Stonham  and  it  was  decided  that  something 
further  must  be  done.  On  the  27th  the  left  hand  was  slightly  swollen  and 
congested  and  the  patient  complained  that  he  could  not  move  the  fingers 
properly. 

*  Italics  mine.  (W.  S.  H.) 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  537 

"  On  June  28th  the  vertebral,  inferior  thyroid,  and  the  third  part  of  the 
axillary  artery  were  ligatured.  A  vertical  incision  was  made  just  external 
to  that  employed  for  the  previous  operation  and  was  carried  further  upwards 
along  the  outer  border  of  the  sternal  head  of  the  sternomastoid.  A  second 
incision  was  made  from  the  lower  end  of  this  outwards  along  the  line  of 
the  clavicle  and  this  triangular  flap  of  skin  was  then  turned  upwards  and 
outwards;  the  remains  of  the  clavicular  head  of  the  sternomastoid  were 
drawn  outwards  and  the  internal  jugular  vein  exposed.  Blunt  dissection 
external  to  the  vein  exposed  the  anterior  scalene  muscle  and  phrenic  nerve. 
The  jugular  vein  was  drawn  inwards  and  the  muscle  outwards.  The  trans- 
verse process  of  the  sixth  cervical  vertebra  was  exposed.  A  vessel  of  no  great 
size  was  now  defined  in  the  position  of  the  vertebral  artery  and  was  liga- 
tured with  silk ;  the  ligature  unfortunately  broke,  dividing  the  vessel,  which 
was  secured  with  difficulty  and  tied  at  both  ends.  No  other  vessel  could  be 
found  in  this  situation,  though  the  foramen  through  the  transverse  process 
could  be  clearly  defined.  A  second  vessel — the  inferior  thyroid  artery — 
was  also  tied.  A  piece  of  gauze  was  carried  to  the  bottom  of  the  wound 
as  a  drain  and  the  incision  was  sutured  with  horsehair.  Ligature  of  these 
vessels  materially  diminished  but  did  not  arrest  the  pulsation  in  the  sac 
and  it  was  therefore  determined  to  apply  a  distal  ligature  to  the  third  part 
of  the  axillary  artery,  and  this  was  accordingly  done  just  above  the  sub- 
scapular branch  and  was  followed  by  complete  arrest  of  the  pulsation. 

"  On  June  29th  the  patient  was  comfortable The  circulation  in 

the  fingers  was  good.  The  wound  in  the  neck  had  oozed  a  little  and  the 
dressing  was  stained;  this  had  been  packed.  On  the  30th  the  wound  was 
dressed  and  a  smaller  plug  of  gauze  was  put  in  the  cervical  wound.  The 
wounds  were  healthy.  On  July  3d  the  patient  was  progressing  satisfactorily 
and  was  kept  on  fluid  diet.  The  dressings  had  not  been  touched.  The  cir- 
culation in  the  arm  was  good  but  no  pulse  was  present  either  at  the  wrist  or 

the  elbow On  the  5th  there  had  been  uninterrupted  progress.   The 

wound  was  dressed  and  the  sutures  and  gauze  plug  were  removed.  No  pulse 
was  to  be  felt.  The  aneurysm  was  decidedly  smaller,  harder  and  denser; 
there  was  no  trace  of  pulsation  in  the  sac.  On  the  11th  the  wounds  were 
soundly  healed.  The  aneurysm  was  still  smaller  and  harder;  over  it  slight 
pulsation  could  be  felt  along  a  transverse  line  ( ?  the  transverse  cervical 
artery).  The  radial  pulse  was  just  perceptible.  The  further  progress  of 
the  case  was  uninterrupted.  The  sac  gradually  diminished  in  size  and  the 
pulse  became  stronger  in  the  radial.  The  patient  complained  for  a  few  days 
of  stiffness  in  the  fingers 

Remarks  by  Mr.  Stonham :   "  In  November  [year  not  stated]  I  saw  the 

patient  and  could  find  absolutely  no  trace  of  the  sac The  movements 

of  the  arm  were  necessarily  weak I  have  seen  this  man  as  lately  as 

March,  1902,  and  he  continues  quite  well.  He  is  doing  light  work  as  a 
carpenter." 

In  Mr.  Stonham's  description  of  the  primary  operation  no  mention  is 
made  of  the  branches  given  off  from  the  first  portion  of  the  artery;  I  pre- 
sume, therefore,  that  he  saw  none  and  consequently  did  not  know  the  posi- 
tion of  his  ligature  in  its  relation  to  any  one  of  them.    Since,  however,  he 


538  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

ligated  the  vertebral  and  inferior  thyroid  arteries  at  the  second  operation 
we  may  infer  that  he  believed  his  ligation  to  have  been  made  proximal  to 
these  branches. 

Stonham's  is  the  only  aneurism  of  the  spontaneous  variety  on  our  list  not 
cured  by  the  simple  ligation  of  the  subclavian  artery.  Since  the  artery 
coursed  high  in  the  neck  and  the  aneurism  was  apparently  at  its  highest 
point,  and  as,  furthermore,  the  ligation  of  the  vertebral  and  inferior  thyroid 
arteries  at  the  second  operation  had  less  effect  on  the  aneurism  than  the 
ligation  of  the  third  part  of  the  axillary,  and  as  the  radial  pulse  reappeared 
24  hours  after  the  first  operation  and  13  days  after  the  second,  I  wonder  if 
this  may  not  have  been  a  case  of  aneurism  due  primarily  to  a  cervical  rib — 
secondarily  perhaps  to  the  syphilis.  It  would  seem  that  there  must  have 
been  a  well  established  anastomotic  circulation  before  the  first  operation. 

Surgeons  have  rarely  noted  the  location  of  the  ligature  in  its  relation  to 
the  origin  of  the  branches  of  the  first  division  of  the  subclavian  artery.  Only 
from  the  cases  in  which  this  relationship  is  known  could  we  find  justification 
for  inference  as  to  the  effect  which  secondary  ligation  of  the  branches  in 
question  might  exert  upon  the  aneurism.  There  can  be  little  doubt,  I  think, 
that  we  should  make  for  ourselves  the  rule  always  to  ligate  as  close  to  the 
aneurism  as  possible,  whether  on  its  afferent  or  efferent  side.  I  have  never 
failed  to  cure  the  aneurism  when  both  the  afferent  and  efferent  arteries  have 
been  ligated  in  accord  with  this  precept.  In  one  instance  of  this  kind,  how- 
ever, the  pulsation,  which  had  ceased  for  a  moment  after  the  ligation  of  the 
artery  on  both  sides  of  the  aneurism,  returned  before  the  toilet  of  the  wound 
was  completed,  but  we  noted  that  the  sac  became  larger  and  tenser — a  sign 
which  I  have  learned  to  regard  as  favorable.  At  the  first  dressing  of  this 
case  of  mine,*  which  was  not  made  until  the  9th  day  after  operation,  the 
tumor  no  longer  pulsated  nor  did  it  ever  pulsate  again.  I  have  read  of  at 
least  two  similar  observations,  but  unfortunately  neglected  to  make  a  memo- 
randum of  either. 

I  do  not  understand  why  Mr.  Stonham  should  have  ligated  the  axillary 
artery  at  so  low  a  point.  A  ligation  as  near  the  aneurism  as  possible  would 
have  been  more  likely  to  cure  it  and  have  less  imperilled  the  circulation  of 
the  arm. 

Pierre  Delbet.  (X.)  Anevrisme  de  la  sous-claviere  gauche.  Bull,  et 
mem.  Soc.  de  Chir.,  Paris,  1910,  t.  xxxvi,  p.  1114.  (Seance  du  16  novembre, 
1910.) 

"  I  have  the  honor  to  present  to  you  a  patient  upon  whom  I  have  operated 
for  a  traumatic  aneurism  of  the  left  subclavian.   I  operated  with  the  assis- 

*  Johns  Hopkins  Hospital,  Surg.  No.  18357. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  539 

tance  of  our  colleague  Pierre  Duval,  whose  counsels  have  been  extremely 
valuable. 

"  I  first  exposed  the  sac,  because  it  was  not  absolutely  certain  that  the 
aneurism  had  its  origin  in  the  subclavian :  it  might  have  developed  at  the 
expense  of  one  of  its  branches. 

"  Then,  I  resected  the  internal  third  of  the  clavicle  and  a  part  of  the 
manubrium  in  order  to  proceed  with  the  search  for  the  subclavian  at  its 
origin  from  the  aorta.  This  was  very  deep.  I  passed  a  ligature  beneath  the 
artery  and,  pulling  on  this  ligature  so  as  to  bend  the  artery  and  stop  the 
circulation  in  it,  I  opened  the  sac.  Formidable  haemorrhage.  Having  tam- 
poned and  made  compression,  I  proceeded  with  the  search  for  the  peripheral 
end  of  the  subclavian,  and  I  passed  a  thread  underneath  it  as  had  been 
done  for  the  central  end.  The  two  ligatures  being  tied,  I  removed  the  tam- 
pon.   Haemostasis  was  not  perfect,  but  the  haemorrhage  was  not  menacing. 

"  We  could  see  the  orifice  through  which  the  blood  came  and  we  closed  it 
with  two  forceps.  In  spite  of  its  deep  location,  it  would  perhaps  have  been 
possible  to  suture  it,  but  I  judged  that  this  would  not  have  been  of  any 
advantage.    I  ligated  with  a  single  ligature  passed  around  the  two  forceps. 

"As  the  patient  had  terrible  neuralgic  pains,  je  resequai  les  deux  der- 
nieres  paires  cervicales*  which  were  imbedded  in  the  fibrous  tissue  forming 
the  sac.  The  pains  completely  disappeared. 

"  But  the  patient  had  irregular  phenomena  of  paralysis,  which  made  one 
think  that  the  first  '  f  ronto-dorsal '  was  wounded.  I  did  not  think  it  neces- 
sary to  search  for  this  root,  the  operation  being  already  traumatic  enough. 

"  The  paralytic  phenomena  persist,  and  I  do  not  know  whether  they  will 
ameliorate,  because  it  is  impossible  for  me  to  determine  whether  the  root 
has  been  divided  by  the  stroke  of  the  knife  and  secondarily  compressed. 

"  The  radial  pulse,  which  was  not  perceptible  before  the  operation,  has 
not  yet  become  so,  but  at  no  time  has  the  nutrition  of  the  member  given  the 
least  anxiety. 

"  I  shall  not  discourse  further  on  this  case,  because  I  have  to  make  a 
report  on  an  analogous  one  of  Dr.  Pierre  Duval."  f 

This  would  seem  to  have  been  a  case  for  extirpation  of  the  sac  rather  than 
for  tamponage. 

Ed.  Schwaetz.  (XL)  Enorme  anevrisme  diffus  du  cou  et  de  la  region 
sous-claviculaire.  Paralysie  du  membre  superieur  gauche.   Compression  du 

♦Presumably  dissected  free  is  meant.  It  is  interesting  to  note  that  the  freeing  of 
the  nerves  entirely  relieved  the  pains.   (W.  S.  H.) 

t  The  case  of  Duval  is  probably  the  one  announced  by  title  at  the  seance  of  April 
20,  1910,  p.  420:  "Anevrisme  de  I'  artere  sous-claviere  droite.  Extirpation  du  sac  apres 
resection  temporaire  de  la  clavicule.  Ligature  laterale  de  la  veine  sous-claviere 
Guerison.  Presentation  de  la  piece  anatomique  et  du  malade,  par  M.  Pierre  Duval, 
chirurgien  des  hopitaux. 

"Le  travail  de  M.  Duval  est  renvoye  a  une  commission,  dont  M.  Delbet  est 
nomme  rapporteur." 


540  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

recurrent  gauche.  Bull,  et  mem.  Soc.  de  Chir.,  Paris,  1910,  t.  xxxvi,  pp.  874 
and  1138. 

Seance  du  20  juillet  1910.  M.  Ed.  Schwartz:  " I  have  the  honor  to  pre- 
sent to  you  this  wounded  man,  for  whose  treatment  I  ask  your  advice 

"  M.  X.,  aet.  33,  was  thrown  from  his  bicycle  against  the  shaft  of  a  cart 
which  struck  him  in  the  left  supraclavicular  region.  The  accident  occurred 
June  6,  1910,  about  6  weeks  ago.  The  patient  did  not  lose  consciousness, 
but  got  up,  and  noticed  at  the  point  where  he  had  been  struck  the  formation 
of  a  swelling  which  increased  as  he  watched  it,  while  the  skin  became  tense 
and  purple.   He  consulted  a  physician  who  ordered  leeches. 

"  He  returned  to  his  home  in  the  evening  and  felt  greatly  oppressed.  The 
leeches  were  applied  and  gave  relief. 

"  At  the  end  of  five  or  six  days  the  tumor  appeared  to  have  diminished, 
the  ecchymosis  disappeared,  the  voice,  which  had  been  a  little  hoarse, 
regained  its  normal  timbre ;  the  patient  remained  in  bed  on  a  strict  diet. 

"  Then  there  occurred  attacks  of  pain  in  the  left  arm,  especially  at  night. 
These  attacks  lasted  about  half  an  hour  and  were  accompanied  by  contrac- 
tion of  the  muscles  of  the  arm.  Pyramidon  was  ordered  for  him,  and  on 
June  13,  1910,  the  actual  cautery  was  applied. 

"  From  June  14th  the  tumor  again  began  to  increase  in  size  and  hardness 
during  three  or  four  days,  and  at  the  same  time  there  appeared  difficulty  in 
breathing,  roughness  of  the  voice,  and  a  complete  flaccid  paralysis  of  the 
left  arm.  The  attacks  of  pain  persisted.  June  24,  1910,  the  patient  entered 
the  Hospital  of  Langres,  where  iodide  of  sodium  was  administered  and 
electric  treatment  of  the  paralyzed  muscles  periodically  given.  As  his  condi- 
tion remained  stationary  he  was  sent  to  the  Hopital  Cochin,  July  18,  1910. 

Examination. — "  One  finds  an  enormous,  tense,  fluctuant  tumor  occupy- 
ing the  whole  left  carotid  and  supraclavicular  regions,  reaching  from  the 
jaw  to  the  clavicle,  and  pressing  the  larynx  and  trachea  to  the  right. 

"  One  perceives  neither  pulsation,  bruit,  nor  expansion  of  the  tumor.  The 
skin  is  movable  over  it. 

"  The  left  temporal  pulse  is  hardly  perceptible ;  the  left  radial  pulse  is 
feebler  than  the  right  but  not  appreciably  retarded. 

"  The  left  arm  is  completely  paralyzed ;  there  is  atrophy  of  the  muscles, 
especially  of  the  great  pectoral ;  the  patient  can  raise  the  shoulder  by  means 
of  the  clavicular  fasciculus  of  the  trapezius ;  sensation  is  preserved. 

"  There  is  raucity  of  the  voice,  which  is  a  little  muffled ;  there  is  dysphagia 
when  solid  food,  especially  bread,  is  taken ;  there  are  signs  of  compression 
of  the  left  great  sympathetic,  manifest  in  the  narrowing  of  the  left  palpebral 
cleft,  in  myosis  and  enophthalmus. 

"  Aspiration  with  a  Pravaz  syringe  drew  out  a  little  black  sanguineous 
liquid. 

"  In  our  opinion,  we  can  only  be  confronted  in  this  instance  with  the 
rupture  of  a  large  vessel  of  the  neck.  In  spite  of  the  absence  of  pulsation, 
we  believe  that  there  is  a  rupture  of  an  artery  like  the  carotid  or  sub- 
clavian; there  have  been  two  affluxes  of  blood,  the  first  at  the  time  of  the 
accident,  the  second  6  days  later  when  the  severe  symptoms  of  paralysis 
appeared. 


LIGATION"  OF  LEFT  SUBCLAVIAN  ARTERY  541 

"  What  treatment  would  you  advise  ?  Were  it  not  for  the  paralysis  and 
the  atrocious  suffering  I  would  await  developments  in  the  hope  of  seeing 
the  tumor  diminish  in  size.  Do  these  symptoms  demand  intervention,  open- 
ing the  sac,  searching  for  and  tying  off  the  torn  ends  of  the  vessel  ? 

"  M.  Lucas-Championniere :  Is  there  definite  amelioration,  or  is  there 
aggravation  ? 

"  M.  Schwartz :  After  a  period  of  augmentation  we  observe  undoubtedly 
a  slight  abatement. 

"  Several  speakers  took  part  in  the  discussion,  some  advising  intervention, 
others  abstention.   It  was  demonstrated  that  the  tumor  was  pulsating." 

Seance  du  23  novembre  1910.  "  Anevrisme  diffus  de  la  sous-claviere 
gauche.  Communication  par  M.  Schwartz."  Bull,  et  mem.  Soc.  de  Chir., 
Paris,  1910,  t.  xxxvi,  p.  1138. 

"  I  presented  to  you  on  the  20th  of  last  July  a  patient  with  an  enormous 
aneurismal  tumor  of  the  neck  following  a  wound  in  the  left  supraclavicular 
triangle,  and  asked  what  course  you  would  counsel  me  to  take  in  such  case. 

"  As  the  tumor  was  increasing  and  the  patient  was  suffering  continuously, 
my  colleague  Nelaton,  who  had  the  goodness  to  give  me  his  valuable  and 
illuminating  advice,  was  with  me  inclined  towards  an  intervention — to 
search  for  the  two  ends  of  the  wounded  artery,  having  first  made  as  far  as 
possible  preventive  occlusion  of  the  wounded  vessel,  which,  as  will  be  remem- 
bered, might  be  the  common  carotid,  but  more  likely  the  left  subclavian  or 
one  of  its  large  branches. 

"After  experiments  on  the  cadaver,  for  which  we  are  indebted  to  the 
kindness  of  our  colleague  Professor  Hartmann,  we  thought  of  proceeding  in 
the  following  manner:  make  a  resection  of  the  internal  extremity  of  the 
clavicle  and  of  the  left  half  of  the  manubrium,  search  for  the  common 
carotid  at  its  origin  from  the  aorta,  apply  a  temporary  ligature  to  this 
artery,  search  for  the  very  deeply  situated  subclavian,  and  against  the 
vertebral  column  make  digital  compression  of  this  vessel  at  its  origin.  Of 
course,  the  ligature  was  not  to  be  permanently  tied  until,  after  splitting  the 
aneurismal  sac,  the  arterial  wound  had  been  located. 

"  In  the  meantime,  I  had  the  patient  injected  subcutaneously  with  10  to 
15  cubes  of  serum  gelatine,  one  each  day.  Under  the  influence  of  this  it 
appeared  to  us  that  the  tumor  diminished;  at  all  events,  the  pains  became 
much  less  intense  and  the  general  condition  improved. 

"  My  colleague  Nelaton  and  I  met  to  decide  and  to  perform  the  projected 
operation.  The  tumor  began  to  grow  anew,  and  it  seemed  to  us  impossible 
to  proceed  with  the  claviculo-sternal  resection  without  entering  the  aneu- 
rismal field  and  being  immediately  inundated  with  blood.  In  view  of  this 
conclusion  we  believed  that  we  should  refrain  from  operation,  and  continue 
to  make  the  injections  of  serum  gelatine  and  the  application  of  bladders  of 
ice.  Meanwhile  my  wards  were  closed  for  repairs  and  the  wounded  man 
passed  into  the  service  of  my  colleague  Quenu,  under  the  care  of  our  col- 
league Pierre  Duval,  who  believed  that  he  ought  to  operate  and  sent  me  the 
following  note : 

'  Operation.— August  8,  1910.  Doubtful  as  to  whether  the  aneurism  had  its  origin 
in  the  common  carotid  or  the  subclavian  it  appeared  to  me  prudent  to  make  a 


542  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

search  for  these  two  vessels  at  their  origin  from  the  aorta,  to  place  on  each  of  them 
a  temporary  ligature,  then,  to  split  freely  the  aneurism  and  to  find  my  way  to  the 
wounded  artery  as  circumstances  might  permit. 

'  Incision  parallel  to  the  clavicle  curving  over  the  manubrium ;  resection  of  the 
clavicle  (inner  half),  of  the  left  half  of  the  manubrium,  and  of  the  first  costal  cartilage. 

'  The  pleura  and  pleural  dome  were  pressed  aside.  The  arch  of  the  aorta  was 
exposed.  A  ligature  was  placed  about  the  left  common  carotid  and  also  on  the  sub- 
clavian.  Free  vertical  incision  of  the  aneurism. 

1  At  the  moment  the  jet  of  blood  spurted  my  assistant  pulled  quickly  on  the  pre- 
cautionary ligatures.  After  evacuation  of  the  clots,  I  easily  found  the  subclavian,  cut 
across  at  the  internal  border  of  the  first,  rib.  Ligature  of  the  two  ends.  Suture  and 
drainage.  The  patient's  pulse  after  operation  was  84.  The  operation  had  lasted  50 
minutes.    At  3  o'clock  in  the  afternoon,  sudden  death. 

'  I  am  persuaded  that  he  died  from  an  embolus.  The  ligature,  placed  as  a  pre- 
caution which  I  now  recognize  as  useless  and  dangerous,  on  the  common  carotid, 
had  been  sharply  drawn,  must  have  wounded  the  internal  coats  of  the  artery,  from 
which  there  was  a  clot  and  mortal  embolus.' 

"  I  cannot,  in  spite  of  the  unsuccessful  outcome,  help  felicitating  our 
colleague  Pierre  Duval  on  the  course  which  he  adopted.  I  allowed  myself 
to  be  halted  through  fear  that  I  should  not  be  able  to  control  the  haemor- 
rhage; the  operation  which  he  performed  has  shown  that  that  fear  was 
unfounded.  He  added  to  the  operation  planned  by  Nelaton  and  me  resec- 
tion of  the  cartilage  of  the  first  rib,  which  gives  still  better  access  and  per- 
mitted the  application  of  a  ligature  to  the  subclavian " 

Whether  the  precautionary  loop  about  the  subclavian  within  the  thorax 
was  tied  is  not  stated.  In  any  event,  the  proximal  ligation  must  have  been 
of  the  first  portion. 

I  am  unable  to  share  with  M.  Duval  his  confident  belief  that  an  embolus 
from  the  carotid  artery  was  the  cause  of  the  patient's  death.  Have  we  any 
proof  that  embolism  of  a  cerebral  artery  has  ever  caused  sudden  death,  or 
have  we  evidence  that,  infection  being  excluded,  emboli  may  become  dis- 
lodged or  a  thrombosis  form  as  the  result  and  at  the  site  of  a  temporary 
ligature?  Many  times  have  I  occluded  temporarily  large  arteries  in  the 
human  subject  and  never  have  I  had  occasion  to  regret  it.  The  aorta  of  dogs, 
which  on  the  average  is  not  larger  than  the  carotid  of  man,  we  have  repeat- 
edly ligated  as  a  temporary  measure  and  have  never  observed  thrombosis 
at  the  line  made  by  the  crushing  ligature.  In  any  event,  the  temporary 
occlusion  of  arteries  should,  when  possible,  be  made  in  a  manner  not  likely 
to  rupture  their  coats. 

I  commonly  employ  a  narrow  tape  in  making  temporary  occlusion.  Close 
to  the  artery  the  two  arms  of  the  tape  are  twisted  and  the  twist  maintained 
by  clamping  it  with  an  artery  forceps.  Dr.  Mack  Rogers  of  Birmingham, 
Alabama,  discussing  the  paper  of  Dr.  Sherrill,  advocates  the  following 
method : 

"  In  connection  with  this  subject  of  aneurysm,  I  desire  to  call  attention 
to  a  method  of  controlling  haemorrhage  that  has  been  of  great  utility  in 
these  cases.  It  is  the  use  of  an  ordinary  white  tape  that  is  used  for  binding 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  543 

purposes.  It  should  be  about  12  inches  long  and  half  an  inch  wide.  An 
aperture  is  provided  about  one  inch  from  the  centre,  through  which  the 
other  end  of  the  tape  is  carried  after  it  has  been  passed  around  the  vessel ; 
then  by  pulling  on  the  two  ends  of  the  tape,  pressure  is  exerted  over  a  broad 
area  of  the  vessel,  controlling  the  haemorrhage  perfectly,  yet  it  does  not 
injure  the  vessel.  By  the  use  of  this  tape  an  assistant  is  in  absolute  control 
of  the  situation.  He  can  increase  or  diminish  the  pressure  on  the  vessel  at 
will,  while  the  operator  is  dealing  with  the  aneurysmal  sac,  and  this  will 
greatly  assist  the  operator  in  locating  the  vessels  that  enter  the  sac. 

"  This  method  of  controlling  haemorrhage  is,  of  course,  not  an  entirely 
new  one,  but  I  wish  to  call  the  attention  of  this  Association  particularly  to 
its  application  in  these  desperate  cases  of  aneurysm." 

Capt.  C.  G.  Browne.  (XII.)  A  case  of  diffuse  traumatic  aneurism  and 
ligature  of  the  first  part  of  the  subclavian.  British  Medical  Journal,  London, 
1911,  vol.  ii,  p.  1534.  (Reports  on  medical  and  surgical  practice  in  the 
hospitals  and  asylums  of  the  British  Empire.  Station  Hospital,  Barrackpore, 
Bengal.) 

"  Ligature  of  the  first  part  of  the  left  subclavian  artery  is  an  operation 
attended  by  many  difficulties  and  dangers.  I  have  only  been  able  to  find 
two  successful  cases  recorded  of  ligature  on  the  right  side  and  none  on  the 
left.  My  references  are,  however,  limited.  Erichsen  condemns  the  operation 
as  '  bad  in  principle,'  and  '  most  unfortunate  in  practice/  and  considers  that 
it  should  be  *  banished  from  surgical  practice/  Hence  a  few  notes  on  a 
recent  successful  case  may  be  of  interest. 

"  Private  C.  was  brought  to  the  hospital  on  the  evening  of  August  25, 
1911.  He  was  faint  and  his  clothes  were  blood-stained.  He  had  been  on 
guard,  had  fainted,  and  fallen  forwards  on  his  bayonet,  the  point  of  which 
had  entered  through  the  left  anterior  axillary  fold  for  an  uncertain  distance. 
There  was  no  bleeding  from  the  wound,  but  there  was  evidence  of  a  collection 
of  blood  in  the  subclavicular  region  and  inner  part  of  the  axilla.  He  com- 
plained of  an  aching  distended  feeling  in  the  arm.  The  wound  was  dressed 
and  pressure  applied.  The  temperature  in  the  evening  was  100.6°. 

"  The  patient  had  a  restless  night,  but  no  external  haemorrhage ;  there 
was  marked  pulsation  and  a  bruit  over  the  subclavian  swelling,  which  had 
not  increased  in  size.  The  left  radial  pulse,  which  was  at  first  feeble,  was  now 
equal  to  the  right.  The  venous  return  from  the  arm  was  apparently  slightly 
obstructed.  The  temperature  was  99.8°  in  the  morning  and  100.4°  in  the 
evening.  He  had  another  restless  night,  and  on  the  morning  of  August  27th 
he  complained  of  severe  pain  down  the  arm,  which  was  slightly  swollen; 
the  pulsation,  bruit,  and  size  of  the  swelling  were  unaltered.  The  tempera- 
ture was  99.6°  in  the  morning  and  100.4°  in  the  evening.  He  had  a  very 
restless  night,  being  almost  delirious  with  pain,  and  had  attempted  to  tear 
off  his  bandage.  Ou  August  28th  the  arm  was  more  swollen,  and  the  obstruc- 
tion to  the  venous  return  was  more  obvious.  I  saw  him  for  the  first  time 
on  this  day  in  consultation  with  Lieutenant-Colonel  F.  J.  Morgan, 
R.  A.  M.  C,  and  decided  to  operate  at  once.   The  temperature  was  99.4°. 

"  Operation,  August  28,  1911. — The  usual  incision  for  ligature  of  the 
third  part  of  the  subclavian  was  made,  the  omo-hyoid  was  pulled  up,  and 


544  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

the  outer  border  of  the  scalenus  anticus  exposed.  Owing  to  the  clavicle  being 
very  much  pushed  upwards  and  forwards,  the  wound  was  of  considerable 
depth.  No  trace  of  either  subclavian  artery  or  vein  could  be  found  external 
to  the  scalenus  anticus  muscle.  The  wound  was  extended  inwards  and  the 
sternomastoid  partially  divided;  the  depth  of  the  wound  increased,  and 
presently  a  large  artery,  partially  overlapped  on  its  inner  side  by  a  vein, 
was  exposed,  descending  vertically  along  the  inner  border  of  the  scalenus 
anticus.  The  wound  was  now  very  deep,  and  the  greatest  care  had  to  be 
exercised.  Unfortunately  at  this  point  a  small  vein  was  torn  close  to  its 
junction  with  the  large  vein  and  the  wound  was  flooded  with  blood.  A  liga- 
ture was  placed  on  this  after  much  trouble  and  waste  of  valuable  time.  The 
artery  was  now  compressed  by  the  finger  and  the  radial  pulse  was  at  once 
obliterated;  pulsation  below  the  clavicle  also  ceased.  The  vessel  was  taken 
to  be  the  first  part  of  the  subclavian  and  was  ligatured.  The  passing  of  the 
ligature  took  some  time,  as  I  had  to  proceed  with  the  utmost  caution,  and 
the  depth  of  the  wound  and  condition  of  the  patient  did  not  warrant  me  in 
tracing  the  artery  any  further.  The  wound  was  sewn  up,  leaving  a  gauze 
drain.  The  axilla  was  then  opened,  clot  and  serum  evacuated,  and  a  large 
drainage  tube  inserted.   The  temperature  in  the  evening  was  102.8°. 

"  On  August  29th  the  part  was  dressed,  a  light  plug  inserted  in  the  upper 
wound,  and  a  tube  left  in  the  lower.  The  temperature  was  99.4°.  He  stated 
that  he  was  absolutely  free  from  pain  in  the  arm  but  there  was  a  slight 
tingling  of  the  fingers.  There  was  no  pulsation  below  the  clavicle  and  no 
radial  pulse.  The  arm  was  kept  swathed  in  cotton  wool. 

"  On  September  4th  he  was  doing  very  well ;  there  was  a  little  serous 
exudation  from  the  upper  wound. 

"  On  September  18th  both  wounds  were  completely  healed ;  there  was 
some  stiffness  about  the  muscles  of  the  shoulder,  which  was  being  massaged. 
No  pulse  could  be  felt  in  the  radial  artery. 

"  On  September  27th  he  was  discharged  from  hospital,  complaining  of 
some  numbness  of  the  first  and  second  fingers. 

"On  October  11th  he  was  marked  *  light  duty'  for  one  week  (before 
resuming  his  full  military  duty  on  October  18th).  No  pulsation  was  felt  in 
the  radial  artery. 

"  The  chief  point  of  interest  about  the  case  was  the  abnormal  course  of 
the  artery.  When  first  exposed  I  thought  it  must  be  the  common  carotid 
from  its  vertical  course.  The  result  of  the  ligature,  however,  leaves  no  doubt 
that  it  was  the  subclavian.  The  vessel  must  have  either  (1)  made  a  very 
high  arch  in  the  neck  on  the  inner  side  of  the  scalenus  anticus,  or  (2)  taken 
origin  from  the  common  carotid  in  the  neck  instead  of  from  the  arch  of  the 
aorta,  though  this  is  an  abnormality  I  have  never  read  of.  The  almost 
immediate  relief  of  the  pain,  presumably  due  to  nerve  pressure,  was  a  grati- 
fying feature.  I  am  indebted  to  Lieutenant-Colonel  F.  J.  Morgan, 
R.  A.  M.  C,  for  his  invaluable  assistance  during  the  operation  and  permis- 
sion to  publish  this  case." 

As  there  was  no  pulsation  in  the  axillary  haematoma  and  no  haemorrhage 
after  evacuation  of  the  clots  it  is  improbable  that  the  axillary  artery  had 
been  pierced  by  the  bayonet.    Possibly  only  a  vein  was  injured.    I  should 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  545 

not  be  inclined  in  a  case  like  this  to  make  a  permanent  ligation  of  the  sub- 
clavian. Compression  of  the  artery  above  the  clavicle  would  have  been 
especially  easy  as  the  artery  coursed  high  in  the  neck. 

The  "  high  arch  in  the  neck  "  of  the  subclavian  artery  must  have  simpli- 
fied the  operation  greatly.  The  former  of  Captain  Browne's  two  conjec- 
tures in  regard  to  the  "  abnormal  course  of  the  artery  "  is  quite  surely  the 
correct  one.  My  studies,  clinical  and  experimental,  on  the  dilatation  of 
arteries  distal  to  the  point  of  coarctation  have  led  me  to  observe  with 
greater  interest  and  care  the  course  of  the  subclavian  artery  in  patients 
with  cervical  ribs  and  also  in  those  without  them,  and  I  have  been  surprised 
at  the  frequency  with  which  the  subclavian  occupies  an  abnormally  high 
position  in  the  otherwise  apparently  normal  neck,  sometimes  quite  as  high 
as  in  people  with  cervical  ribs. 

My  colleague,  Professor  Howland,  recently  called  my  attention  to  a 
child's  neck,  the  configuration  and  great  length  of  which  convinced  him 
that  the  boy  had  a  cervical  rib  or  ribs.  The  subclavian  artery  coursed  so 
high  above  the  clavicle  that  from  this  sign  alone  I  was  quite  sure  that 
Dr.  Howland's  interpretation  was  correct.  The  skiagraph  showed  abnor- 
mally large  transverse  processes  of  the  seventh  cervical  vertebrae,  but  no 
trace  of  cervical  ribs.  We  shall  follow  skiagraphically  the  development  of 
the  neck  of  this  boy  in  the  expectation  that  the  unossified  primordium 
(Anlage)  for  a  cervical  rib  may  be  present. 

Is  it  not  probable  that  the  occurrence  of  very  high  subclavian  arteries 
in  people  without  cervical  ribs  may  be  traceable  to  an  Anlage  for  the  unde- 
veloped ribs?  We  have  several  times  found  in  these  cases  stumps  of  bone 
articulating  with  the  transverse  processes  of  the  seventh  cervical  vertebrae, 
and  in  one  such  case  there  were  definite  s}anptoms  of  pressure  on  the  roots 
of  the  brachial  plexus,  sj-mptoms  which  were  relieved  by  the  removal  of 
the  abnormal  stump  of  bone,  although  at  the  operation  in  this  case  we 
found  nothing  to  explain  the  relief  afforded  by  it. 

I  hope  that  some  younger  men  who  read  the  above  paragraphs  may  be 
interested  to  note  skiagraphically  for  a  period  of  years  the  cervical  develop- 
ment of  children  with  abnormally  long  necks  and  high  subclavian  arteries. 

James  M.  Neff.  (XIII.)  Ligation  of  the  first  portion  of  the  left  sub- 
clavian artery.  With  report  of  a  recent  successful  case.  Annals  of  Surgery, 
Phila.,  1911,  vol.  liv,  p.  503. 

"  Mr.  H.  W.,  age  23  years,  single.  In  December,  1909,  patient  first  noticed 
an  enlargement  of  the  glands  in  the  left  side  of  the  neck. 

"  Patient  entered  the  Deaconess  Hospital,  Spokane,  on  February  11,  1910. 
In  left  side  of  neck  there  was  a  chain  of  enlarged  lymphatic  glands  extend- 
36 


546  LIGATION  OF  LEFT  SUBCLAVIAN  ARTEKY 

ing  from  the  mastoid  process  to  the  clavicle.  The  centre  of  the  mass  was 
more  prominent,  tender  to  pressure,  and  presented  deep  fluctuation.  There 
was  considerable  periadenitis,  the  glands  being  adherent  to  each  other  and 
quite  immovable.   Examination  of  heart,  lungs,  and  abdomen  negative. 

"  Operation,  February  12,  1910. — An  incision  was  made,  extending  from 
the  mastoid  process  downward  along  the  anterior  border  of  the  sternomas- 
toid  muscle  to  the  middle  of  the  neck,  then  backward,  severing  the  muscle, 
and  continuing  downward  to  the  clavicle  along  its  posterior  border.  The 
chain  of  enlarged  glands  was  reached  through  this  incision,  and  their 
removal  begun  from  below  by  clearing  the  space  between  the  internal  jugular 
vein  and  the  clavicle.  The  glands  and  infiltrated  gland  bearing  tissue  in 
this  situation  were  dissected  free  with  some  difficulty,  but  without  apparent 
injury  to  any  of  the  important  structures  in  the  neighborhood.  The  lower 
angle  of  the  wound  was  then  tamponed  to  produce  distension  of  the  internal 
jugular  vein,  and  the  dissection  of  the  glands  was  continued  in  an  upward 
direction.  This  was  accomplished  with  a  good  deal  of  difficulty,  owing  to 
the  extensive  periadenitis  and  suppuration  in  the  centre  of  the  mass.  It  was 
finally  completed,  however,  and  we  were  about  ready  to  close  the  wound, 
when  there  was  a  sudden  gush  of  blood  from  the  lower  part  of  the  wound 
behind  the  clavicle.  The  haemorrhage  was  very  profuse  and  came  on  without 
the  slightest  warning,  as  we  had  been  working  in  the  upper  part  of  the  neck 
and  had  not  touched  the  lower  portion  since  the  beginning  of  the  operation. 
The  flow  of  blood  was  stopped  by  pressure  with  the  fingers  behind  the  clavi- 
cle, and  the  field  cleared  by  sponging.  An  examination  was  then  made  and 
it  was  found  that  the  haemorrhage  had  come  from  the  subclavian  artery 
just  internal  to  the  scalenus  anticus  muscle.  By  cautiously  moving  the  fin- 
gers inward,  the  outer  border  of  the  small  opening  in  the  artery  was  revealed. 
A  haemostat  was  then  placed  on  the  vessel  in  this  situation  and  two  more 
to  the  inner  side  of  the  first,  thus  closing  the  opening.  The  wound  in  the 
neck  was  now  closed  in  the  usual  manner,  after  uniting  the  cut  ends  of 
the  sternomastoid  muscle  with  catgut  sutures.  A  drainage  tube  was  placed 
in  the  upper  part  of  the  wound  on  account  of  the  secondary  infection,  and 
the  haemostats  were  allowed  to  protrude  through  the  lower  angle  of  the 
incision. 

"  Patient  was  returned  to  bed  in  fair  condition,  with  pulse  110  and  tem- 
perature 100.8°  F. 

"  On  February  14th,  48  hours  after  operation,  the  haemostats  were  care- 
fully removed  and  two  moderately  firm  gauze  packings  were  inserted,  one 
upon  the  other  behind  the  clavicle  and  down  to  the  artery.  No  bleeding 
occurred  immediately  after  the  removal  of  the  forceps,  but  three  hours 
later  the  patient  had  a  very  severe  haemorrhage  which  stopped  spontane- 
ously. The  outer  packing  was  then  removed  and  replaced  by  a  firmer  one, 
which  was  held  in  position  by  a  tight  adhesive  plaster  drawn  across  the 
wound  and  over  the  shoulder.  After  the  haemorrhage  the  patient  was 
anaemic  and  pulse  went  up  to  118.  On  February  18th,  four  days  later, 
there  having  been  no  haemorrhage  in  the  interval,  the  outer  packing  was 
removed,  but  the  one  next  to  the  artery  left  undisturbed.  The  wound  looked 
well,  though  there  was  slight  purulent  discharge  from  the  upper  part 
through  the  drainage  tube.  Pulse  112,  temperature  101.6°  F.  Early  the 
next  morning,  11  hours  after  the  last  dressing,  patient  had  another  very 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTEKY  647 

severe  haemorrhage.  On  the  19th  he  became  delirious  and  on  the  20th  had 
two  more  haemorrhages.  From  this  date  until  the  25th  there  were  no  haemor- 
rhages, his  pulse  went  down  to  98,  temperature  nearly  to  normal,  and  we 
were  greatly  encouraged  about  his  condition.  On  February  25th  another 
severe  haemorrhage  occurred,  and  between  this  date  and  March  4th,  a  period 
of  seven  days,  he  had  14  haemorrhages  of  greater  or  less  severity.  During 
this  time  the  temperature  ranged  from  99.6°  to  101°  F.  On  February  2?th 
cultures  were  taken  by  Dr.  Frank  Hinnian  from  the  pus  in  the  drainage 
tube  for  the  purpose  of  making  autogenous  vaccines.  On  this  date,  slight 
oedema  of  the  arm  and  weakening  of  the  radial  pulse  were  noted,  the  result 
of  long-continued  pressure  on  the  subclavian  artery  [/Sic].  On  March  3d 
Dr.  Hinnian  injected  150,000,000  bacteria  in  right  arm.  On  March  4th, 
condition  of  patient  became  so  grave  that  we  decided  that  his  only  hope 
lay  in  the  ligation  of  the  first  division  of  the  subclavian.  This  procedure  had 
been  considered  several  times  before,  but  as  we  had  been  unable  to  find  in 
the  literature  the  report  of  a  single  successful  case  of  ligation  of  the  first 
portion  in  the  presence  of  sepsis,  we  had  looked  upon  the  operation  as  a  last 
resort.  At  the  time  we  decided  to  ligate  the  artery  our  patient  had  a  tem- 
perature of  103.6°  F.,  pulse  160,  and  he  was  delirious  from  anaemia  and 
sepsis.  For  five  hours  before  the  operation  we  kept  up  continuous  digital 
compression  of  the  artery,  as  the  haemorrhage  would  recur  whenever  the 
pressure  was  released. 

*  Operation,  March  4,  1910,  7.30  p.  m. 

"  Before  beginning  the  operation  an  intravenous  saline  transfusion  was 
given  in  the  median  basilic  vein  of  the  right  arm. 

"  An  incision  was  made  along  the  upper  border  of  the  clavicle,  from  the 
outer  third  to  the  sternoclavicular  articulation  and  then  upward  for  2-J 
inches  through  the  old  incision  along  the  posterior  border  of  the  sternomas- 
toid.  An  abscess  cavity  containing  several  drachms  of  foul-smelling  pus 
was  found  beneath  the  latter  muscle.  The  clavicle  was  divided  with  bone- 
cutting  forceps  1-J  inches  from  the  sternum,  and  the  ends  retracted  in  a 
downward  direction,  thus  giving  good  access  to  the  subclavian  space.  Up  to 
this  time  pressure  on  the  subclavian  had  been  maintained,  but  when  all 
was  in  readiness  the  pressure  was  released  and  the  packing  removed.  A  gush 
of  blood  immediately  followed  but  was  at  once  controlled  by  direct  pressure 
with  the  fingers,  followed  by  the  application  of  haemostats  to  the  opening 
in  the  artery.  The  scalenus  anticus  was  next  divided,  the  thyroid  axis  and 
vertebral  artery  recognized,  and  the  subclavian  dissected  free  in  a  downward 
direction  from  the  surrounding  structures.  The  dissection  was  particularly 
difficult  because  of  the  previous  operation  and  the  infection  of  the  field, 
which  had  caused  a  matting  together  of  all  the  tissues.  By  careful  work, 
however,  the  subclavian  and  innominate  veins  were  isolated  and  drawn  for- 
ward and  the  thoracic  duct  recognized  and  separated  from  the  artery.  After 
the  vessel  was  completely  isolated,  two  attempts  were  made  to  ligate  it  in 
the  upper  portion  of  the  first  division,  but  both  ligatures  cut  through  the 
outer  coats  and  had  to  be  removed.    Finally  three-quarters  of  an  inch  * 

*I  am  surprised  to  learn  that  division  of  the  clavicle  1%  inches  from  the  sternum 
should  have  permitted  an  exposure  sufficient  to  enable  the  operator  to  apply  a  ligature 
so  close  to  the  aorta.    (W.  S.  H.) 


548  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

above  the  aorta  the  wall  was  strong  enough  to  tolerate  a  ligature,  and  a 
double  strand  of  medium  sized  silk  on  an  aneurism  needle  was  passed  from 
below  upward,  behind,  and  around  the  vessel.  This  double  ligature  was  tied 
in  a  simple  square  knot  (not  the  Ballance  and  Edmunds  stay  knot)  just 
tight  enough  to  occlude  the  artery  and  stop  pulsation.  A  haemostat  was  then 
clamped  on  the  vessel  about  one-quarter  inch  distal  to  the  ligature.  Another 
double-silk  ligature  was  tied  around  the  artery  distal  to  the  opening  in  its 
wall  and  a  second  haemostat  applied  proximal  to  it.  The  thyroid  axis,  verte- 
bral and  internal  mammary  arteries  were  then  ligated  with  silk  and  the 
forceps  removed  from  the  wound  in  the  subclavian.  A  loose  packing  of 
iodoform  gauze  was  placed  in  the  deep  cavity  behind  the  clavicle,  the  ends 
of  the  clavicle  united  with  aluminum  bronze  wire,  and  the  external  wound 
closed  with  interrupted  silkworm  gut  sutures. 

"  "When  the  patient  was  returned  from  the  operating  room,  his  pulse 
was  140  and  temperature  103°  F.  For  ten  days  after  operation  the  blood 
pressure  was  kept  below  112  mm.  of  mercury  by  diminishing  the  amount 
of  ingested  liquids  and  giving  spirits  of  nitroglycerin  whenever  it  reached 
that  point. 

"  Restlessness  was  controlled  by  hypodermics  of  morphine.  Five  days 
after  operation  the  autogenous  vaccines  were  again  given  and  repeated  every 
three  or  four  davs  thereafter.  The  temperature  ranged  from  102.2°  F.  to 
104.2°  F.  and  pulse  120  to  150,  until  March  19th,  15  days  from  time  of 
operation,  after  which  both  gradually  went  down  to  normal.  Patient  con- 
tinued delirious  at  intervals  until  March  15th.  The  haemostats  were  re- 
moved from  the  ligated  vessels  on  March  13th,  nine  days  after  operation. 
On  March  13th,  he  developed  a  right-sided  pleurisy  and  cough,  with  yellow- 
ish expectoration.  His  temperature  was  103°  F.  to  104°  F.  and  pulse  130 
to  140  for  a  few  days,  but  the  trouble  entirely  subsided  within  a  week.  On 
March  19th  the  ends  of  the  clavicle,  which  had  become  separated,  were 
reunited.  He  was  allowed  out  of  bed  for  the  first  time  on  March  20th, 
16  days  after  operation.  The  wound,  which  was  infected  at  the  time  of 
operation,  continued  to  suppurate  until  the  patient  left  the  hospital  on 
April  2d,  although  it  filled  rapidly  with  granulations  and  was  about  flush 
with  the  clavicle  at  the  time  of  his  discharge. 

"  The  radial  pulse  disappeared  when  the  artery  was  ligated  and  has  not 
returned  to  date,  16  months  after  operation. 

"  The  peripheral  circulation  remained  good  after  the  ligation  and  the 
hand  and  arm  were  warm  at  all  times. 

"  Marked  atrophy  of  the  arm,  forearm,  and  hand  took  place  during  the 
two  or  three  months  following  operation,  and  there  was  great  weakness  of 
all  the  muscles  of  the  left  upper  extremity  from  shoulder  to  fingers. 

"  Tactile  and  pain  sense  were  abolished  over  the  lower  third  of  the  fore- 
arm, hand,  wrist,  and  fingers  for  four  months,  and  muscular  sense  in  the 
hand  was  greatly  impaired  for  the  same  time. 

"  As  a  result  of  almost  constant  exercise,  frequent  massage,  and  faradic 
electricity  to  the  weakened  and  atrophied  muscles,  the  muscular  power  is 
now  about  normal  and  the  muscles  have  regained  their  normal  volume  and 
tone.  There  still  remains,  however,  slight  impairment  of  tactile  sense  in 
the  tips  of  the  fingers.  The  general  health  of  the  patient  at  the  present  time 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  549 

is  perfect,  weight  up  to  normal,  and  he  is  able  to  attend  to  his  regular  busi- 
ness affairs." 

Dr.  Neff  is  to  be  congratulated  on  his  rare  good  fortune  in  not  losing  the 
patient,  and  thanked  for  courageously  narrating  unhappy  experiences  which 
so  clearly  convey  messages  of  warning. 

The  major  errors  in  Neff's  case  were  (1)  the  leaving  of  haemostats  hang- 
ing in  the  wound;  (2)  the  attempt  to  control  the  infection  of  the  wound  by 
vaccination  rather  than  by  antiseptics;  (3)  the  postponement  of  operation 
for  the  arrest  of  bleeding  until,  after  about  a  score  of  secondary  haemor- 
rhages, the  patient  had  become  exsanguinated;  (4)  the  ligation  of  the 
branches  of  the  first  portion  of  the  subclavian  (thyroid  axis,  vertebral,  inter- 
nal mammary)  unless,  as  the  author  probably  believed,  the  condition  of  the 
subclavian  precluded  ligation.  The  operator  should  consider  how  the  closure 
of  an  artery  permanently  clamped  in  continuity  may  be  accomplished. 
Surely  the  intimal  surfaces  which  cannot  adhere  under  ligature  or  band 
even  when  brought  together  in  the  gentlest  manner  cannot  do  so  when  com- 
pressed under  a  crushing  haemostat.  Nor  can  organization  of  the  remaining 
shreds  of  the  arterial  wall  take  place  under  the  spring  of  the  clamp.  In  the 
absence  of  infection  the  artery  may  be  sealed  by  endothelial  proliferation 
and  by  adhesion,  perhaps,  of  the  intimal  surfaces  held  in  contact  for  a  short 
distance  on  both  sides  of  the  clamp.  In  the  presence  of  infection  the  closure 
may,  of  course,  be  effected  by  the  organization  of  a  thrombus. 

Hans  Rubritius.  (XIV.)  Die  chirurgische  Behandlung  der  Aneurysmen 
der  Arteria  subclavia.  Beitrage  z.  klin.  Chirurgie,  Tiibingen,  1911,  Bd. 
lxxvi,  p.  144. 

"  P.  L.,  aet.  21,  laborer.  Entered  the  Prague  Clinic  October  2,  1909. 
On  September  13,  1909,  he  was  stabbed  in  a  brawl  in  the  left  side  of  the 
neck.  Violent  bleeding  followed,  which  was  controlled  by  a  firm  bandage. 
Later  he  was  brought  to  the  dispensary,  where  Primararzt  Dr.  Rosier  ob- 
served that  there  was  virtually  no  bleeding,  but  there  was  a  high  grade  of 
anaemia.  As  no  haemorrhage  occurred  in  the  days  following,  the  wound 
was  simply  dressed  aseptically.  September  20,  1909,  on  changing  the  dress- 
ing, a  considerable  swelling  was  noticed  in  the  left  supra-clavicular  region, 
in  which  in  the  following  days  a  pulsation  developed.  On  the  assumption 
that  it  was  a  case  of  false  aneurism  of  the  carotid,  Dr.  Rosier  sent  the  patient 
to  the  clinic. 

"  Examination. — Middle-sized  man,  well  nourished.  Lungs  and  heart 
sound.  In  the  left  supraclavicular  region  there  is  a  pulsating  tumor  the  size 
of  a  fist,  at  the  summit  of  which,  close  to  the  outer  edge  of  the  left  sterno- 
mastoid,  there  is  a  scar  about  1  cm.  long.  On  auscultation  there  is  heard 
over  the  tumor  a  systolic  bruit,  which  is  also  audible  over  the  axillary  artery. 
The  left  radial  pulse  is  weaker  than  the  right.    Blood  pressure  measured 


550  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

with  the  Gartner  tonometer  is,  right,  70-75  mm.  Hg.,  left,  60-65.  The  left 
arm  is  slightly  cyanotic,  but  there  is  no  swelling  or  dilation  of  the  veins. 
Movements  in  the  left  shoulder  joint  are  somewhat  impeded. 

"  Diagnosis. — False  aneurism  of  the  left  subclavian  artery. 

"  Operation  I,  October  5,  1909. — Anaesthetic,  Billroth  mixture.  Length 
of  operation  1^  hours.  Skin  incision  over  the  tumor  downwards  to  the 
middle  of  the  clavicle,  which  was  cut  through  in  its  centre  with  a  Gigli  saw. 
It  now  developed  that  the  aneurism  was  situated  very  far  central  on  the 
subclavian,  indeed  in  its  middle  portion.  In  order  to  approach  the  artery 
so  that  it  could  be  ligated  central  to  the  aneurism,  the  sternal  half  of  the 
clavicle  was  completely  removed,  and  a  piece  of  the  first  rib  about  4  cm. 
long  was  resected;  also  the  left  half  of  the  manubrium  had  to  be  taken  away. 
Now  for  the  first  time  it  was  possible  to  reach  the  central  pole  of  the  tumor 
and  to  expose  the  artery  at  its  origin.  In  dissecting  the  artery  the  pleura 
was  wounded,  and  with  a  hissing  sound  pneumothorax  developed.  Carefully 
protecting  the  very  full  subclavian  and  jugular  veins,  between  these  two 
vessels  with  the  aid  of  a  curved  foreign-body  forceps  a  thin  rubber  tube  was 
drawn  around  the  artery.  The  ends  of  the  tube  were  now  made  fast  to  a 
probe  about  20  cm.  long  in  order  that  by  twisting  the  probe  the  tube  might 
be  gradually  tightened,  and  thus  by  degrees  compression  of  the  artery  be 
brought  about.  Tampon  of  the  large  wound ;  dressing. 

"  In  the  course  of  the  next  24  hours  the  probe  was  twice  rotated  through 
180  degrees. 

"  Operation  II,  October  27,  1909. — Examination  shows  that  the  pleural 
cavity  is  distended  with  air  and  the  heart  completely  pushed  to  the  right. 
The  tumor  in  the  left  supraclavicular  region  now  pulsates  no  longer.  At  the 
point  where  the  rubber  tube  had  been  two  strong  silk  threads  were  placed 
around  the  subclavian  artery,  thus  doubly  ligating  it. 

"  Some  days  thereafter  there  appeared  an  exudate  in  the  pleural  cavity ; 
at  first  only  blood  was  obtained  by  aspiration ;  as  this  soon  became  fetid  an 
operation  was  undertaken  on  November  15th.  An  incision  10  cm.  long  was 
made  between  the  7th  and  8th  ribs,  a  piece  of  the  8th  rib  resected,  the  pleura 
opened  and  drained  with  a  rubber  tube. 

"  November  16,  1909,  drain  removed  from  the  pleura.  The  wound  result- 
ing from  the  first  operation  decreased  gradually;  at  the  site  of  the  aneu- 
rismal  tumor  one  feels  a  firm  mass.  The  left  radial  pulse  is  not  palpable ; 
the  left  arm  shows  muscular  atrophy,  but  except  for  this  there  is  no  dis- 
turbance of  motion The  patient  was  discharged  December  1,  1909. 

"On  December  10,  1909,  Herr  Primararzt  Dr.  Rosier  stated  that  the 
patient,  a  few  days  after  his  discharge  from  the  clinic,  again  made  applica- 
tion to  be  admitted  to  the  Aussiger  Spital.  On  admission  it  was  found  that 
he  had  fever  and  that  the  entire  left  half  of  the  thorax  was  dull.  Soon 
thereafter  a  great  quantity  of  foul-smelling  pus  emptied  itself  spontaneously 
out  of  the  wound  from  which  the  rib  had  been  resected.  A  drainage  tube 
was  again  inserted.  According  to  a  further  communication  on  April  18, 
1910,  from  Dr.  Rosier  the  secretion  still  persisted,  hence  he  was  again 
admitted  to  our  clinic. 

"April  19,  1910. — The  patient  is  found  to  be  greatly  emaciated  and 
anaemic.  The  left  lung  is  markedly  retracted,  pulmonary  resonance  is  pres- 


LIGATION  OF  LEFT  SUBCLAVIAN  AETEEY  551 

ent  only  to  the  middle  of  the  scapula.  In  the  posterior  axillary  line  at  the 
level  of  the  8th  rib  there  is  a  fistulous  opening  which  leads  far  into  the 
pleural  cavity  and  from  this  a  purulent  secretion  runs  continuously. 
Accordingly,  on  the  25th  of  April  a  thoracoplastic  operation  was  done. 
After  reflecting  a  great  flap,  8  or  10  cm.  of  the  7th,  8th,  9th,  and  10th  ribs 
were  resected,  and  the  skin-flap  turned  into  the  great  hole.  Not  until  the 
middle  of  June  did  the  secretion  begin  to  decrease.  On  the  30th  of  June 
the  wound  was  completely  healed  and  the  patient  was  discharged." 

No  statement  is  made  in  regard  to  the  fate  of  the  haematoma.  Presum- 
ably it  became  infected  and  was  thus  dissipated. 

The  case  of  Eubritius  is  another  to  emphasize  the  importance  of  closing 
wounds,  and  not  only  those  made  for  the  ligation  of  large  arteries.  It  was 
clearly  an  error  in  the  first  instance  to  have  undertaken  to  occlude  gradually 
the  subclavian  artery  of  a  youth  and,  particularly  so,  by  a  method  which 
prevented  closure  of  the  wound.  I  have  found  no  evidence,  after  a  careful 
survey  of  all  the  recorded  cases,  to  sustain  the  fear  that  gangrene  may  fol- 
low the  uncomplicated  ligation  of  any  portion  of  either  subclavian  artery; 
there  was,  therefore,  no  indication  for  the  attempt  to  occlude  the  artery 
gradually,  and  particularly  none  by  a  method  which  superimposed  the  dan- 
ger from  infection — to  the  wound,  to  the  artery,  and  to  the  opened  pleural 
cavity.  The  gangrene  which  followed  the  difficult  and  brilliantly  executed 
operation  of  Matas  M  for  arterio-venous  fistula  of  the  right  subclavian  ves- 
sels seems  quite  unquestionably  to  have  been  chiefly  due  to  the  derangement 
of  the  arterial  and  venous  flow  incident  to  the  fistula.  The  ligation  of  the 
branches  of  the  first  and  second  portions  of  the  artery  may  also  possibly 
have  been  a  determining  factor. 

Although  sternly  disapproving  of  the  method  pursued  by  Eubritius  in 
the  management  of  his  case,  I  can  endorse  in  greater  part  his  generalizations 
in  respect  to  the  treatment  of  subclavian  aneurisms: 

"  We  believe  that  one  should  always  first  test  the  central  ligation ;  if  this 
intervention  has  been  simple  and  accomplished  in  a  short  time  one  may 
proceed  to  make  a  peripheral  ligation  and  perhaps  an  incision  into  and  a 
clearing  out  of  the  aneurismal  sac.  If  the  operation  has  been  difficult  and 
the  condition  of  the  patient  such  that  one  dare  not  venture  to  do  more,  the 
surgeon  should  rest  content  with  the  central  ligation. 

"  Usually  this  operation  alone  will  accomplish  the  desired  result.  When 
not,  then  must  one  at  a  second  operation  make  the  peripheral  ligation  and 
incise  the  aneurism.  This  is  the  operation  which  Hofmann  *  proposed  at 
the  initiative  of  von  Mikulicz.  We  believe  that  this  latter  procedure  deserves 
serious  heeding  under  the  pictured  circumstances ;  and  contrary  to  the  views 

*  "  H.  Hofmann.  Zur  operativen  Behandlung  d.  Aneurysmen.  Beitr.  z.  klin.  Chir., 
Tub.,  1899,  xxiv,  p.  418." 


552  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

of  v.  Frisch  *  and  Saigo,f  who  advise  extirpation  in  every  case,  we  would 
pronounce  the  central  ligation  as  the  operation  of  choice  in  the  treatment 
of  subclavian  aneurisms,  as  already  Oberst  \  and  Rotter  §  have  done." 

G.  P.  Newbolt.  (XV.)  A  case  of  aneurism  of  the  second  and  third 
parts  of  the  left  subclavian  artery  in  a  woman.  British  Medical  Journal, 
London,  1912,  vol.  ii,  p.  867. 

"  Miss  E.,  aged  50,  consulted  me  on  February  3,  1912,  concerning  a  pul- 
sating swelling  at  the  root  of  her  neck  on  the  left  side  which  filled  up  tht 
hollow  above  her  collar-bone.  This  swelling  had  existed  for  three  years  in 
spite  of  treatment.  It  pulsated  and  the  pulsation  was  distensile.  The  swell- 
ing involved  the  second  and  third  parts  of  the  left  subclavian  artery  and 
the  tumour  extended  into  the  axilla,  where  it  could  easily  be  felt.  At  one 
place  above  the  collar-bone  the  swelling  seemed  to  be  just  under  the  skin 
and  threatened  to  come  through.    The  inner  margin  extended  well  under 

the  outer  border  of  the  sternomastoid  muscle Her  doctor  (W.  H. 

Carse,  of  Rochdale)  informed  me  that  she  had  had  marked  endarteritis 
three  years  ago,  when  the  vessels  of  her  right  arm  were  affected  and  her  right 
radial  pulse  disappeared." 

The  patient  was  admitted  to  the  Royal  Southern  Hospital  March  2,  1912. 

"  On  March  14th  I  tied  the  first  part  of  her  left  subclavian  artery. 

"  An  incision  6  or  7  inches  long  was  made  down  the  line  of  the  sterno- 
mastoid on  to  the  sternum,  taking  the  sternoclavicular  joint  as  the  centre 
of  the  incision.  A  second  incision  was  made  at  right  angles  to  the  first 
extending  along  the  collar-bone.  Flaps  were  turned  up  and  the  collar-bone 
was  exposed  at  its  inner  end.  This  structure  was  cleared  by  dividing  the 
clavicular  portion  of  the  sternomastoid,  and  a  rib  elevator  was  passed  under 
it,  followed  by  a  Gigli's  saw,  with  which  the  bone  was  divided,  the  sternal 
end  being  turned  inwards  and  dissected  out.  A  small  vein  connecting  the 
internal  and  external  jugulars  was  tied,  but  there  was  practically  no  bleed- 
ing. The  sternohyoid  muscle  was  defined  with  dissecting  forceps  and  par- 
tially divided.  The  internal  jugular  was  very  large  and  there  was  a  high 
innominate  junction,  so  that  these  veins  practically  filled  the  floor  of  the 
wound.  By  working  down  on  the  inner  side  of  the  internal  jugular,  the 
common  carotid  was  exposed  with  the  pneumogastric  nerve  lying  on  its 
outer  side  and  behind.  The  big  veins  were  now  retracted  downwards  and 
outwards,  and  by  drawing  the  carotid  to  the  inner  side  the  subclavian  was 
felt  pulsating  deep  down  between  the  two.  A  vein  crossing  this  space  was 
tied,  but  the  inferior  thyroid  vein  was  left  untouched,  and  by  scraping  down 

*  "  Otto  v.  Frisch.  Beitrag  zur  Behandlung  peripherer  Aneurysmen.  Arch.  f.  klin. 
Chir.,  Berlin,  1906,  lxxix,  p.  515." 

t "  K.  Saigo.  Traumatische  Aneurysmen  im  Japanisch-Russischen  Kriege.  D. 
Zeitschr.  f.  Chir.,  Leipz.,  1906,  lxxxv,  p.  577." 

t "  Oberst.  Das  Aneurysma  der  Subclavia.  Beitr.  z.  klin.  Chir.,  Tub.,  1904,  xli,  p.  459." 

§  "  Rotter.  Zwei  Falle  von  traumatischen  Aneurysma.  Zentralbl.  f.  Chir.,  Leipz., 
1906,  xxxiii,  p.  783." 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  553 

with  a  blunt  dissector  the  artery  was  exposed  for  a  space  of  about  three 
quarters  of  an  inch.  The  sheath  was  opened  and  the  vessel  found  to  be  quite 
healthy.  An  aneurysm  needle  was  passed  from  the  inner  side  armed  with  a 
catgut  ligature,  and  by  means  of  the  latter  a  loop  of  thick  silk  was  drawn 
under  the  vessel.  The  latter  was  secured  by  tying  the  silk  in  two  places  with 
just  enough  force  to  occlude  the  vessel  without  damaging  its  coats.  These 
ligatures  were  placed  one-half  inch  apart,  but  one  end  of  each  was  left 
uncut,  and  these  were  tied  together.  A  reef  knot  was  used.  Pulsation  at 
once  stopped  in  the  aneurysm.  The  wound  was  closed  without  drainage,  but 
the  cavity  was  obliterated  as  much  as  possible  by  bringing  divided  structures 
together.   The  arm,  which  was  quite  warm,  was  wrapped  in  cotton-wool. 

"  The  operation  took  40  minutes,  but  was  not  hurried  over,  and  it  was 
not  as  difficult  as  might  have  been  expected There  was  no  haemor- 
rhage. The  vessel  lay  very  deep  at  a  distance  of  from  two  and  a  half  to 
three  inches  from  the  surface The  subsequent  history  was  unevent- 
ful as  far  as  recovery  went. 

"  On  the  15th  she  was  very  well,  and  her  right  carotid  pulse  was  84;  no 
pulsation  could  be  felt  in  the  left  radial,  but  her  fingers  were  warm,  and 

she  moved  them  easily.  There  was  no  tingling  of  the  fingers On  the 

16th  she  complained  of  a  little  pain  down  the  left  arm.  On  the  21st  ...  . 
she  had  only  a  little  tingling  in  her  fingers.  March  23d  ....  the  stitches 
were  removed;  the  wound  had  healed,  and  the  sac  was  hard  and  did  not 
pulsate ;  she  felt  quite  well  and  wanted  to  sit  up.  On  April  5th  ....  the 
aneurysmal  swelling  was  smaller  and  decidedly  softer,  but  there  was  no 
pulsation,  and  the  swelling  in  the  axilla  was  much  smaller;  there  was  no 
pulsation  in  the  radial  at  the  wrist.  On  April  15th  there  was  a  small  ulcer 
over  the  lower  part  of  the  scar  on  the  chest,  and  this  was  dressed.  The  swell- 
ing in  the  neck  now  felt  like  a  soft  cyst,  and  the  axillary  sac  was  smaller 
and  harder 

"  On  May  10th  she  returned  home,  exactly  eight  weeks  after  ligature 
of  the  vessel,  there  being  no  sign  of  pulsation  in  the  sac,  which  was  rapidly 
disappearing.  She  was  able  to  raise  her  arm  fairly  well,  and  could  place  her 
hand  to  the  back  of  her  head.  The  small  ulcer  on  the  scar  had  practically 
healed.  On  June  8th  I  saw  her ;  she  was  very  well,  and  her  only  trouble  was 
the  limitation  in  the  power  of  abduction.  The  aneurysm  had  practically  dis- 
appeared, but  her  left  hand  was  decidedly  colder  than  her  right 

".  .  .  .  This  successful  case  is,  of  course,  well  known  as  the  .first,  if  not 
the  only  one,  in  this  country.  The  vessel  has,  I  believe,  been  tied  by  Halsted, 
J.  K.  Rodgers,  and  by  Schumpert,  but  I  am  not  familiar  with  the  results 
of  these  cases " 

Mr.  Newbolt  erred  in  believing  that  he  was  the  first,  in  his  country,  to 
ligate  the  left  subclavian  artery  in  its  first  portion.  Stonham  reported  a 
successful  case  in  1902  (I.  c,  no.  IX),  and  Browne  another  in  1911  (I.  c, 
no.  XII).    Sir  Wm.  Banks  attempted  the  ligation  in  1903  (Z.  c). 

Professor  Wietixg.  (XVI.)  Die  Unterbindung  der  Arteria  subdavia 
sin.  in  ihrem  I.  Abschnitt.  Zentralblatt  f.  Chirurgie,  Leipzig,  1912,  Bd. 
xxxix,  p.  1156. 


554  LIGATION  OF  LEFT  SUBCLAVIAN"  ARTERY 

P.  1157.  "Aneurysma  spurium  traumaticum  A.  subclaviae  durcli 
S-Geschoss." 

"  December  26,  1911.  The  patient,  male,  aet.  35,  ...  .  was  shot  in  the 
left  shoulder,  the  projectile  entering  the  back  at  the  upper  inner  angle  of 
the  shoulderblade.  He  immediately  coughed  up  blood  and  was  referred  to  the 
first  aid  military  dressing  station,  whence  two  days  later  he  was  sent  on  foot 
to  Gulhane,  arriving  in  a  weakened  condition. 

"Examination. — The  entrance  wound,  about  1  cm.  in  diameter,  is  in- 
flamed at  the  edges,  and  is  situated  behind  at  the  upper  inner  angle  of  the 
left  shoulderblade.  There  is  no  exit  wound.  The  X-rays  show  the  projectile 
behind  about  the  middle  of  the  clavicle.  Above  and  on  the  clavicle,  begin- 
ning about  3  cm.  from  the  left  sterno-clavicular  articulation  and  reaching 
to  the  shoulder  joint  is  a  strongly  pulsating  tumor,  about  half  the  size  of  a 
goose  egg.  Ecchymosis  extends  over  the  whole  left  side  of  the  neck  to  the 
nape,  and  downwards  on  the  thorax  to  the  pelvis.  The  pulsating  swelling 
extends  far  into  the  depths  towards  the  back,  and  can  be  felt  to  within  a 
few  centimeters  of  the  entrance  wound.  The  external  jugular  vein  is  visibly 
dilated.  The  radial  pulse  is  absent,  otherwise  the  nutrition  of  the  arm,  with 
the  exception  of  slight  venous  hyperaemia,  is  not  disturbed.  But  there  is 
complete  paralysis  of  the  left  arm  up  to  and  including  the  shoulder,  while 
sensation  is  intact.  The  patient  complains  of  shooting  pains  in  the  left  arm. 

"  A  few  times  there  was  expectoration  of  bloody  sputum,  but  this  has 
ceased.  The  left  side  of  the  thorax  is  completely  filled  with  blood.  General 
condition  is  tolerably  good. 

"Diagnosis. — Gunshot  wound  of  the  left  subclavian  artery  above  the 
clavicle  with  traumatic  spurious  aneurism;  whether  the  subclavian  vein  is 
also  wounded  cannot  be  determined.  Compression  and  perhaps  partial  lacera- 
tion of  the  brachial  plexus ;  wound  of  the  left  pleural  apex  and  lung  and  a 
left -sided  haemothorax. 

"  A  compressive  bandage  was  applied  in  order  to  promote  the  formation 
of  collateral  circulation.  The  pressure  had  no  favorable  influence  on  the 
aneurism  itself;  on  the  contrary,  it  was  extending  towards  the  skin  and 
towards  the  back,  and  also  somewhat  medially.  Rupture  through  the  skin, 
which  is  very  thin  over  the  tumor,  appears  imminent.  Indication  is  vital. 

"  The  plan  of  operation  is  to  reach  the  left  subclavian  artery  central  to 
the  aneurismal  sac,  to  clamp  it  temporarily,  and  then  to  remove  the  haema- 
toma,  in  order,  if  feasible,  to  close  the  wound  in  the  vessel. 

"  First  of  all,  it  was  intended  to  search  for  the  left  subclavian  artery  near 
its  origin  from  the  arch  of  the  aorta,  using  the  common  carotid  artery  as  a 
guide.  The  internal  jugular  vein  must  be  sacrificed,  the  vagus  nerve  and 
the  thoracic  duct  must  be  spared.  The  space  central  to  the  aneurism  is 
small,  hardly  3  cm.  broad,  therefore  it  is  best  to  resect  the  clavicle  centrally, 
in  order  to  make  room. 

"  In  order  to  establish  blood  depots  the  veins  of  both  legs  and  of  the  left 
arm  were  occluded  by  a  constricting  bandage.  The  right  arm  was  left  free 
for  pulse  control  and  a  possible  infusion. 

"  Operation,  January  If,  1912. — Incision  over  the  left  sternoclavicular 
joint,  beginning  on  the  right  at  the  inner  end  of  the  right  clavicle ;  on  the 
left,  ending  temporarily  before  the  aneurism.  Dissection  of  the  left  sterno- 
mastoid,  and  of  the  sternolaryngeohyoid-bone  muscles  with  ligation  of  the 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  555 

neighboring  veins.  In  the  depths  one  can  feel  the  pulsating  dome-like  sac 
projecting  outwards  and  backwards.  The  external  jugular  vein,  greatly 
compressed  and  thrust  forward,  was  doubly  ligated.  Now  the  median  end 
of  the  left  clavicle  was  snipped  off  in  pieces  for  2  cm.  with  the  cutting  for- 
ceps, since,  from  behind,  the  aneurism  left  no  space.  In  the  same  way, 
starting  at  the  sternoclavicular  joint,  a  piece  of  the  sternum  was  removed. 
Thus,  the  common  carotid,  the  vagus  nerve  and  the  innominate  vein  were 
well  exposed.  The  V.  jug.  comm. — huge  at  this  point — was  doubly  ligated 
with  celluloid  thread  1  cm.  above  its  junction  with  the  subclavian  vein  and 
divided ;  the  left  vertebral  vein  was  treated  in  the  same  manner.  Now  the 
subclavian  artery,  ascending  in  an  arch,  was  well  exposed.  The  thoracic  duct 
was  left  outside  and  above,  lying  close  to  the  aneurism.  The  common  carotid 
artery  with  the  vagus  nerve  was  drawn  strongly  inwards  with  a  blunt  retrac- 
tor, the  innominate  vein  downwards.  Compression  of  the  ascending  portion 
of  the  subclavian  artery  caused  all  pulsation  in  the  aneurism  to  cease;  for 
this  reason  a  thick  celluloid  thread  in  a  Deschamps  needle  was  temporarily 
placed  around  the  artery  and  a  half  knot  made  so  that  in  case  of  need  it 
could  be  drawn  taut.  The  temporary  clamping  was  done  with  the  rubber- 
covered  artery  clamp  of  Hopfner-Stich. 

"  The  skin  incision  was  now  lengthened  superficially  outwards  to  the 
shoulder,  and  the  aneurism,  which  lay  close  under  the  skin,  was  opened 
wide.  The  projectile  lay,  dull  end  foremost,  not  far  behind  the  clavicle  near 
the  inner  edge  of  the  sac.  About  300  c.  cm.  of  spongy  black  coagulum  and 
fluid  blood  were  evacuated  with  the  finger  from  a  cavity  which  was  deep, 

extending  almost  to  the  nape,  and  behind  the  clavicle  and  first  rib 

From  the  walls  of  the  aneurismal  sac  there  is  moderately  abundant  arterial 
and  venous  bleeding,  so  that  exploration  of  its  great  cavity  is  difficult.  As 
the  condition  of  the  patient  would  not  admit  of  prolonging  the  narcosis  in 
order  to  search  for  the  site  of  the  wound,  and  since  sewing  it  up  at  the  great 
depth,  although  certainly  possible,  would  be  very  uncertain  and  time- 
consuming,  it  was  abandoned.  The  ligature  around  the  subclavian  artery 
was  tied  and  this  wound  entirely  sewed  up.  The  aneurismal  sac  was  firmly 
stuffed  with  gauze  and  the  overlying  skin  temporarily  closed.  Pressure  band- 
age over  the  wound. 

"  After  the  operation  the  patient  was  soon  in  good  spirits.  There  was  no 
cerebral  disturbance.  The  left  arm  remained  nourished  as  formerly.  As  the 
ligation  was  done  central  to  the  vertebral  artery  and  the  thyroid  axis  and 
likewise  the  internal  mammary,  the  collateral  circulation  was  assured.* 
The  pains  in  the  left  arm  diminished.  Unfortunately  on  the  following  day 
marked  paresis  of  the  right  arm  was  noticed,  which  was  referable  to  the 
compression  of  the  pressure-bandage  on  the  right  plexus.  This  paralysis,  of 
which  that  of  the  radial  nerve  continued  the  longest,  soon  subsided. 

*  An  incorrect  assumption,  it  seems  to  me,  for  the  enumerated  branches  of  the  first 
portion  had  been  blocked  on  both  sides,  centrally  by  the  ligature  and  distally  by  the 
stuffing  in  the  aneurismal  sac.  A  ligature  applied  distal  to  the  origin  of  these  branches 
would  less  have  imperiled  the  circulation  of  the  arm.  The  circulation  would  never- 
theless be  carried  on  by  the  anastomoses  of  these  branches  of  the  first  portion  of  the 
subclavian.  The  closer  the  ligature,  central  or  peripheral,  to  the  sac  the  better. 
(W.  S.  H.) 


556  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

"  On  the  8th  day  the  outer  stitches  over  the  tampon  were  removed  with- 
out haemorrhage.  The  great  cavity  is  clean.  New  light  tampon  with  iodo- 
form gauze.  January  13,  1912.  Very  light  tampon  with  new  compress 
bandage.  The  left  arm  is  somewhat  swollen  from  too  tightly  drawn  bandage. 
January  16,  1912.  The  cavity  is  fast  getting  smaller,  principally  through 
expansion  of  the  lung.  In  front  pulmonary  resonance,  behind,  dullness  to 
the  spine  of  the  scapula. 

"  Two  months  after  operation  the  patient  left  the  hospital  with  the  wound 
healed.  Pulse  in  the  radial  artery  is  still  absent.  Motility  in  the  left  arm  is 
slowly  returning;  fingers  and  elbow  can  be  moved.  Further  news  of  the 
patient  not  obtainable." 

The  day  is,  I  trust,  near  when  to  pack  a  wound  in  order  to  arrest 
haemorrhage  except  under  compelling  circumstances  will  be  considered 
reprehensible. 

V.  Gaudiani.  (XVII.)  Ligation  of  the  first  part  of  the  left  subclavian 
for  aneurism.  Medical  Record,  New  York,  1915,  vol.  lxxxvii,  p.  331.  New 
York  Academy  of  Medicine.   Stated  meeting,  held  January  8,  1915. 

"  Dr.  V.  Gaudiani  presented  a  man,  46  years  old,  who  came  under  his 
care  in  May,  1913.  He  had  had  luetic  infection  20  years  before,  but  had 
never  taken  any  treatment.  A  few  months  before  he  had  noticed  a  pulsating 
tumor  of  the  size  of  an  egg  rising  from  the  sternal  notch  and  extending 
behind  the  sternocleidomastoid  muscle.  He  did  not  show  any  other  trouble 
with  the  exception  of  an  area  of  anaesthesia  on  the  inner  side  of  the  forearm, 
and  a  dilatation  of  the  left  pupil.  A  murmur  could  be  heard  over  the  tumor ; 
this  was  also  audible  along  the  axillary  vessels.  Although  the  case  had  been 
considered  an  inoperable  one,  Dr.  Gaudiani  advised  a  central  ligation  of 
the  subclavian.  The  operation  was  performed  under  intratracheal  insuffla- 
tion to  prevent  possible  pneumothorax.  An  incision  was  made  from  the 
manubrium  of  the  sternum,  curving  upward  over  the  sternocleidomastoid 
muscle,  and  reaching  down  the  outer  extremity  of  the  clavicle.  Such  an 
incision  was  decided  on  because  it  would  permit  eventually  the  resection  of 
the  sternum  or  clavicle  and  allow  also  a  peripheral  ligature  in  case  the  cen- 
tral was  not  feasible.  After  the  muscle  had  been  cut  through,  the  tumor 
appeared  covered  by  the  internal  jugular  and  by  the  upper  part  of  the  vena 
anonyma.  The  former  was  ligated  and  severed  and  the  latter  was  gently 
pulled  down.  By  means  of  blunt  dissection  it  was  possible  to  penetrate 
behind  the  sternum,  along  the  carotid,  until  central  compression  of  the 
aneurism  was  possible.  Such  compression  stopped  the  pulsation  in  the  sac 
and  the  radial  pulse.  A  silk  ligature  was  passed  and  a  stop  knot  was  made. 
The  patient  made  a  good  recovery  and  he  could  now  attend  to  his  duties  in 
iron  foundry  work.  No  radial  pulse  could  be  felt.  The  stretching  and  isola- 
tion of  the  subclavian  loop  of  the  sympathetic  nerve,  known  as  the  ansa 
Vieussensi,  which  surrounded  the  sac,  could  explain  the  mydriasis  of  the  left 
pupil." 

The  aneurism  seems  to  have  been  of  the  first  portion  of  the  subclavian; 
presumably  no  branches  were  given  off  between  the  ligature  and  the  prox- 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  557 

imal  pole.  The  patient  made  a  good  recovery  and  resumed  work  in  a  foun- 
dry. Nothing  is  said  about  the  fate  of  the  aneurism.  He  was  observed 
seven  months  or  less. 

Cabl  A.  HAMAxy.  (XVIII.)  Ligation  of  the  first  part  of  the  left  sub- 
clavian artery.  Annals  of  Surgery,  Philadelphia,  1918,  vol.  lxviii,  p.  219. 

"  E.  R.,  aged  50  years,  had  an  aneurism  about  1  inch  in  diameter,  involv- 
ing the  third  portion  of  the  left  subclavian  artery,  which  had  been  noticed 
for  about  one  year ;  there  were  no  marked  evidences  of  pressure  on  the  vein 
or  nerves,  though  he  had  some  pain.  Wasserinann  reaction  negative.  There 
was  a  moderate  degree  of  arteriosclerosis  and  the  arch  of  the  aorta  was  some- 
what dilated. 

"He  was  operated  upon  at  Charity  Hospital  May  10,  1917. 

"  The  third  portion  of  the  artery  was  exposed  by  the  usual  incision,  and 
it  was  found  that  the  dilatation  extended  beneath  the  scalenus  amicus :  this 
muscle  was,  therefore,  divided  after  displacing  the  phrenic  nerve.  The  sub- 
clavian and  internal  jugular  veins  and  thoracic  duct  and  vagus  nerve  were 
held  aside  and  the  first  portion  of  the  artery  well  exposed :  it  was  somewhat 
dilated.  A  double  ligature  of  braided  silk  was  passed  around  the  vessel  and 
firmly  tied.  Pulsation  in  the  sac  ceased  at  once  and  did  not  return. 

"  The  wound  healed  per  primam  and  no  disturbances  in  the  circulation 
of  the  upper  extremity,  except  for  the  absence  of  the  pulse  beyond  the  liga- 
ture, ever  appeared.  The  sac  contracted  into  a  small  firm  mass  and  when 
last  seen,  four  or  five  months  afterwards,  the  patient  was  quite  well. 

"  In  this  case  the  branches  of  the  subclavian  were  not  tied,  as  has  been 
suggested  and  practised  by  a  number  of  surgeons,  in  order  to  lessen  the  dan- 
gers of  secondary  haemorrhage." 

Dr.  Hamann  did  well  to  refrain  from  tying  the  branches  of  the  subclavian. 
The  danger  of  secondary  haemorrhage  is  practically  nil  in  the  absence  of 
infection  and  if  the  ligation  is  properly  performed. 

The  first  portion  of  the  subclavian  was  so  easily  and  so  well  exposed  that 
it  would  seem  to  have  coursed  high  in  the  neck.  It  is  interesting  to  note 
that  the  artery  was  somewhat  dilated  at  the  site  of  the  ligature.  We  have, 
I  think,  good  reason  to  believe  that  the  danger  of  ligating  dilated  or  dis- 
eased arteries  is  overestimated.  I  have  twice  successfully  ligated  a  dilated 
innominate  artery,  and  Col.  J.  S.  White  has  ligated  the  base  of  an  aneurism 
without  mishap  (vid.  Case  No.  XIX  of  our  table). 

J.  Stn-ct.atr  White.  (XIX.)  Traumatic  aneurism  of  the  left  subclavian 
artery:  successful  ligation  at  the  junction  of  the  first  and  second  portions. 
British  Medical  Journal,  London,  1918,  vol.  ii,  p.  131. 

"  The  treatment  of  aneurysm  of  the  left  subclavian  artery  by  ligature  of 
the  vessel  always  presents  considerable  difficulties,  which  are  the  greater  the 
nearer  the  ligature  is  applied  to  the  origin  of  the  artery.   From  the  experi- 


558  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

ence  of  the  following  case,  I  have  been  led  to  draw  certain  conclusions,  which 
are  set  out  at  the  end  of  the  report. 

"  Pte.  M.,  aged  35  years,  sustained  a  gunshot  wound  of  the  chest  on 
August  16,  1917,  at  Ypres.  The  bullet  entered  behind  to  the  left  of  the  third 
dorsal  vertebra  and  escaped  just  above  the  clavicle  at  a  point  corresponding 
to  the  junction  of  the  middle  and  inner  thirds  of  the  bone.  He  spat  blood 
for  a  day  or  two  afterwards,  but  the  wound  progressed  favourably,  and  on 
August  30th  he  was  transferred  to  England.  By  September  3d  his  wound 
was  soundly  healed.  There  was  partial  paralysis  of  the  left  deltoid  muscle, 
for  which  daily  massage  and  galvanism  were  prescribed.  He  continued  to 
pick  up  until  November  16,  when  a  pulsating  swelling  appeared  at  the  root 
of  the  neck.  It  had  all  the  characters  of  an  aneurysm,  and  as  it  steadily 
increased  in  size,  Colonel  A.  M.  Connell,  assisted  by  Major  E.  F.  Finch, 
operated  on  December  8th.  The  swelling  proved  to  be  a  saccular  aneurysm 
arising  from  the  second  part  of  the  subclavian  artery.  Owing  to  the  dense 
matting  of  the  tissues  around  the  aneurysm  the  placing  of  a  proximal  liga- 
ture was  not  attempted.  Instead  a  stout  catgut  strand  was  tied  around  the 
base  of  the  aneurysm  where  it  sprang  from  the  upper  convex  margin  of 
the  artery. 

"  This  procedure  was  for  a  time  followed  by  marked  improvement,  and 
both  swelling  and  pulsation  almost  entirely  disappeared.  Then  the  aneu- 
rysm began  to  enlarge  again,  and  by  the  end  of  December  it  had  become 
obvious  that,  unless  something  further  could  be  done,  it  was  merely  a  ques- 
tion of  how  long  he  would  live.  In  view  of  its  position  and  the  knowledge 
that  one  would  have  to  conduct  a  deep  dissection  through  tissues  distorted 
by  inflammatory  exudate  and  containing  vessels  and  nerves  of  the  first 
importance,  further  operative  measures  could  not  be  lightly  entertained,  but, 
as  the  alternative  seemed  wholly  black,  the  facts  of  his  case  were  placed 
clearly  before  him,  and  he  elected  to  be  operated  on  a  second  time.  The 
operation  took  place  on  January  2,  1918,  under  chloroform  anaesthesia 
given  by  Captain  N.  Milner.  I  had  the  valuable  assistance  of  Major  G. 
Wilkinson  and  Major  E.  F.  Finch. 

"Operation,  January  2,  1918. — The  steps  of  the  operation  were:  (1) 
Removal  of  the  scar  of  the  first  operation,  together  with  some  unhealthy 
granulation  tissue.  (2)  Subperiosteal  resection  of  the  inner  half  of  the 
clavicle.  The  sternal  attachments  of  the  bone  were  not  divided,  and  the 
decorticated  bone  was  made  to  pivot  over  to  the  right  after  being  surrounded 
by  gauze.  (3)  A  long  and  tedious  dissection  involving  the  ligation  and 
division  of  several  veins,  injury  to  the  thoracic  duct  or  one  of  its  branches, 
from  which  much  milky  fluid  escaped,  and  identification  of  the  subclavian 
and  internal  jugular  veins  and  the  lower  part  of  the  scalenus  anticus  muscle. 
(4)  Careful  division  of  the  scalene  muscle  with  a  small  scalpel  from  with- 
out inwards.  The  fibres  were  divided  close  to  the  rib  and  very  cautiously, 
taking  especial  care  not  to  encroach  on  the  anterior  or  internal  portions 
of  the  muscle  sheath.  (5)  The  subclavian  artery  at  the  junction  of  its  first 
and  second  portions  was  ligatured  with  a  double  strand  of  No.  1  Van  Horn's 
catgut  after  it  had  been  ascertained  that  occlusion  of  the  artery  at  this 
point  controlled  the  circulation  in  the  aneurysm.  (6)  The  displaced  portion 
of  the  clavicle  was  fixed  in  position  by  strands  of  catgut  passed  through 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  559 

holes  drilled  in  the  bone,  and  the  extensive  wound  closed  by  a  series  of 
superimposed  catgut  sutures,  a  small  rubber  tube  being  left  in  for  72  hours. 

"  Aseptic  healing  followed,  and  beyond  a  small  mass  of  cicatricial  tissue 
no  local  evidence  of  the  aneurysm  can  be  discerned. 

"  I  am  indebted  to  Captain  J.  E.  Stacey  for  the  notes  of  the  case. 

"  The  lessons  which  I  have  learnt  from  a  study  of  this  case  are : 

"  1.  To  be  prepared  to  meet  with  extraordinary  difficulty  in  exposing  the 
artery  on  account  of  inflammatory  exudate  caused  by  the  bullet  or  shell 
fragment. 

"  2.  The  value — indeed  I  might  say  the  necessity — of  resecting  the  clavi- 
cle in  order  to  secure  adequate  room. 

"  3.  The  advantage  to  be  derived  from  dividing  the  scalenus  anticus 
muscle  in  the  way  I  have  described.  By  the  judicious  use  of  small  retractors 
after  its  division  it  is  possible  to  draw  inwards  the  phrenic  nerve  and  to  dis- 
place the  pneumogastric  and  sympathetic  nerves,  together  with  the  other 
important  structures  lying  to  the  inner  side  of  the  muscle,  and  so  reach  the 
distal  part  of  the  first  portion  of  the  artery." 

Should  this  case  be  regarded  as  a  ligation  of  the  first  portion  of  the  artery  ? 
To  question  it  is  perhaps  to  quibble.  Inasmuch  as  the  clavicle  and  the 
scalenus  anticus  muscles  were  divided,  it  would  have  been  quite  as  easy  to 
ligate  the  artery  definitely  in  its  first  portion  unless  the  superior  intercostal 
branch  were  just  proximal  to  the  site  of  ligation.  In  any  event  the  operator 
did  well  to  ligate,  as  I  presume  he  did,  distal  to  the  superior  intercostal 
artery  and  as  close  to  the  aneurism  as  feasible. 

Sie  Charles  Ball  an  ce.  (XX.)  A  case  of  ligation  of  the  first  part  of 
the  left  subclavian  artery.  Journal  of  the  Royal  Army  Medical  Corps,  Lon- 
don, 1918,  vol.  xxxi,  p.  417. 

"  Private  K.,  Dublin  Fusiliers,  aged  31,  was  admitted  to  Cottonara  Hos- 
pital, Malta,  under  the  care  of  Lieutenant-Colonel  Dundon,  R.  A.  M.  C,  on 
January  13,  1918,  from  Saloniki. 

"History. — Before  joining  the  Army  he  had  been  in  the  Navy,  from 
which  he  was  discharged ;  reason  unknown.  No  history  of  syphilis.  In  July, 
1916,  he  was  wounded  by  a  shrapnel  bullet  in  the  left  supraclavicular  region. 
The  wound  was  just  above  the  middle  of  the  clavicle  and  had  healed.  He 
had  recently  had  an  attack  of  tertian  malaria. 

"  On  Admission. — Patient  complains  of  numbness  and  shooting  pains  in 
the  left  arm  and  hand  with  muscular  weakness.  A  well  pulsating  tumour 
can  be  seen  and  felt  above  the  left  clavicle ;  an  area  of  dullness  continuous 
with  this  swelling  extends  for  two  inches  below  the  inner  half  of  the  clavicle. 
The  radial  pulse  can  only  just  be  felt  at  the  wrist  but  the  arm  is  quite 
warm.  X-ray  examination  shows  the  presence  of  a  tumour,  part  of  which 
is  in  the  chest  cavity,  and  the  rest,  curving  over  the  first  rib,  extends  into 
the  root  of  the  neck.  It  seems  more  dense  in  the  lower  part,  probably  on 
account  of  organized  blood  clot  in  the  aneurysmal  sac.  A  shrapnel  bullet  is 
lodged  in  the  right  side  of  the  chest  at  the  level  of  the  seventh  rib.  It  has 
not  been  definitely  localized  as  there  is  no  likelihood  of  its  being  removed. 
A  diagnosis  of  aneurysm  of  the  second  and  third  portions  of  the  left  sub- 


560  LIGATION"  OF  LEFT  SUBCLAVIAN  ARTERY 

clavian  artery  was  made  and  it  was  decided  to  ligate  the  subclavian  on  the 
proximal  side  of  the  aneurysm.  Antisyphilitic  remedies  had  no  effect. 

"  Operation,  February  ]+,  1918. — A  general  anaesthetic  was  given  by 
Lieutenant-Colonel  Shirley  with  the  Vernon-Harcourt  apparatus.  An  inci- 
sion was  made  along  the  anterior  border  of  the  lower  half  of  the  sterno- 
mastoid  down  to  the  manubrium  and  another  horizontally  along  the  inner 
half  of  the  clavicle.  The  common  carotid  artery,  internal  jugular  vein,  and 
vagus  nerve  were  exposed  in  the  middle  of  the  neck  and  the  dissection  was 
continued  downwards,  keeping  well  towards  the  middle  line  of  the  neck,  as 
the  wall  of  the  aneurysm  extended  in  this  direction  and  was  very  thin.  The 
fingers  of  the  left  hand  protected  the  wall  of  the  aneurysm  from  injury. 
More  room  was  required,  so  the  inner  third  of  the  clavicle  was  resected,  by 
division  with  a  Gigli  saw  and  disarticulation  at  the  sternoclavicular  joint. 
The  dissection  became  increasingly  difficult,  the  aneurysm  and  internal 
jugular  vein  had  to  be  gently  pressed  outwards  with  the  fingers  while  the 
common  carotid  artery  and  vagus  nerve  were  retracted  inwards  with  a  cop- 
per retractor.  The  deeper  part  of  the  tumour  was  nearer  the  middle  line 
than  the  superficial  part ;  the  vessel  had  probably  been  injured  at  the  junc- 
tion of  the  first  with  the  second  part,  and  the  aneurysm  had  developed  in 
front  of  the  artery  and  displaced  it  and  the  dome  of  the  pleura  backwards 
as  it  increased  in  size.  It  had  extended  below  the  first  rib  through  the  upper 
opening  of  the  thorax.  At  last  the  vertebral  vein  was  recognized  and  behind 
it  the  artery  was  both  seen  and  felt.  It  was  cleared  and  ligated  with  three 
medium-sized  strands  of  kangaroo  tendon  tied  in  a  stay  knot.  Pulsation  in 
the  aneurysm  immediately  ceased.  The  patient  left  the  table  in  good  con- 
dition. I  was  admirably  assisted  in  the  operation  by  Captain  James  Ander- 
son, R.  A.  M.  C. 

"Progress. — No  untoward  symptoms  followed  the  operation  and  the 
wound  healed  throughout  by  first  intention.  Five  weeks  after  operation  the 
patient  had  an  attack  of  malaria ;  tertian  parasites  were  found  in  the  blood. 
Tartar  emetic  (0.04  to  0.12  gramme)  and  quinine  bihydrochloride  (15 
grains)  were  injected  intravenously  on  alternate  days.  The  fever  did  not 
recur. 

"  Radiograms  taken  after  the  operation  show  progressive  consolidation 
of  the  aneurysm.  This  is  most  marked  in  the  upper  part.  Before  operation 
the  part  above  the  clavicle  showed  no  defined  border  but  only  a  fluffy  edge 
from  the  constant  pulsating  movement  during  the  exposure  of  the  plate. 
In  the  later  photograph  taken  some  time  after  the  operation  this  upper  part 
shows  a  well-defined  outline. 

"  With  the  contraction  of  the  aneurysm  the  pain  and  weakness  of  the 
upper  extremity  exhibited  week  by  week  progressive  improvement. 

"  No  evident  inconvenience  resulted  from  the  loss  of  the  inner  third  of 
the  clavicle ;  the  arm,  when  he  left  the  hospital,  was  in  excellent  condition 
and  could  be  moved  in  any  direction.  The  clavicle  became  fixed  to  the 
first  rib. 

"  The  rarity  of  ligation  of  the  first  part  of  the  left  subclavian  gives  an 
interest  to  this  case." 

W.  S.  Halsted.    (XXI.)    (Pages  487  to  491.) 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  561 

Sir  William  H.  Banks.  Unsuccessful  attempt  to  ligate  the  first  portion 
of  the  left  subclavian  artery.  Liverpool  Medical  Institute.  Meeting  of 
December  18,  1902.  Lancet,  London,  1903,  vol.  i,  p.  103. 

"  In  the  second  case  degeneration  of  the  artery  was  unlikely,  as  the  patient 
was  a  young,  healthy  man,  the  condition  being  due  to  a  railway  crush.  The 
aneurysm  had  spread  into  the  neck  and  was  as  much  subclavian  as  axillary. 
With  the  aid  of  his  colleague,  Mr.  Paul,  Sir  William  Banks  made  a  strenu- 
ous attempt  to  ligature  the  first  part  of  the  left  subclavian  artery  in  the 
thorax;  the  pleura  was  a  good  deal  injured  and  the  patient  died  from 
pleurisy." 

The  above  is  the  entire  memorandum. 

J.  Garland  Shebeill.  Report  of  a  case  of  aneurism,  with  a  new  method 
of  ligature  of  the  left  subclavian.  Transactions  of  the  Southern  Surgical 
and  Gynecological  Association,  1911,  vol.  xxiii,  p.  190. 

"  In  January,  1910,  a  colored  man,  aged  30  years,  was  admitted  to  the 
hospital ;  family  history  negative ;  .  .  .  .  chills  and  fever  at  the  age  of  19. 
....  He  had  had  occasional  pain  in  the  chest  since  August,  1908 

"  In  August,  1909,  he  was  injured  in  the  subclavian  region  of  the  left 
side  by  a  wagon  crank ;  followed  within  one  month  by  a  swelling  in  the  same 
region,  which  remained  a  few  weeks  and  became  smaller ;  to  be  followed  in  a 
short  time  by  another  enlargement  in  the  same  region,  which  also  remained 
about  a  month  and  became  smaller.    The  present  tumor  began  to  enlarge 

about  December  15,  1909,  and  had  gradually  increased  in  size At 

present  he  complains  of  pain  and  tenderness  in  the  left  shoulder,  also  suffers 
tenderness  just  above  the  spine  of  the  left  scapula  and  in  the  left  axilla. 

"  When  I  first  saw  him  about  January  1,  1910,  he  had  a  pulsating  tumor 
about  the  size  of  a  small  melon  situated  at  the  upper  part  of  the  thorax, 
extending  from  near  the  median  line  and  just  above  the  level  of  the  clavicle 
downward  and  outward  almost  to  the  margin  of  the  pectoralis  major  muscle. 
This  tumor  pulsated  synchronously  with  the  heart  and  was  distinctly  expan- 
sile in  character.  No  distinct  bruit  could  be  heard  over  the  tumor,  but  an 
accentuated  second  sound  of  the  heart  was  easily  detected.  The  patient  had 
an  almost  imperceptible  pulse  in  the  left  radial,  and  it  was  delayed  some- 
what compared  to  that  of  the  right  radial.  The  pulse  of  the  left  carotid  was 
synchronous  with  that  of  the  right  radial.  Patient  had  no  tracheal  tug;  had 
no  marked  dyspnoea,  although  he  was  more  comfortable  sitting  up  in  bed. 
He  had  no  cough  and  no  interference  with  deglutition  or  respiration.  A 
diagnosis  of  subclavian  aneurysm  was  made,  and  the  various  methods  of 
treatment  were  discussed  with  the  patient  and  with  several  physicians  in 
attendance. 

"  Distal  ligation  of  the  subclavian  was  considered  inadvisable  owing  to 
the  distance  the  tumor  extended  out  upon  the  chest,  and  also  because  we 
believed  that  this  measure  would  not  prove  curative.  Ligature  in  the  first 
portion  anteriorly  was  not  to  be  considered  owing  to  the  position  of  the 
tumor,  which  would  have  interfered  greatly  with  the  accomplishment  of 
37 


562  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

that  step.  After  discussing  the  merits  of  wiring  the  sac  and  the  possibility 
of  complete  cure  if  we  could  successfully  ligate  the  subclavian  in  the  first 
portion  of  its  course  by  attacking  it  from  the  posterior  surface  of  the 
thorax,  the  patient  decided  to  accept  the  latter  method. 

"  Operation. — On  January  27,  1910,  the  subclavian  was  tied  a  short  dis- 
tance from  its  origin  at  the  aorta.  The  operation  was  performed  in  the  fol- 
lowing manner:  An  incision  was  made  along  the  posterior  margin  of  the 
scapula  about  four  inches  long,  dividing  the  skin  and  the  muscles  attached 
to  the  posterior  portion  of  this  bone.  It  was  joined  by  an  incision  running 
inward  from  its  inferior  extremity  to  the  spinous  process.  A  similar  incision 
was  carried  from  its  upper  end  in  towards  the  spine.  The  soft  tissues  were 
dissected  from  the  ribs  with  the  skin  and  all  haemorrhage  controlled.  The 
second,  third  and  fourth  ribs  were  removed  for  a  distance  of  about  three 
inches.  The  intercostal  muscles  were  lifted  off  the  pleura;  the  latter  was 
gently  pushed  downward  and  outward  with  the  finger,  and  the  subclavian 
artery  readily  came  into  view  as  it  left  the  aorta  at  the  level  of  the  fourth 
dorsal  vertebra.  A  small  opening  was  made  in  its  sheath  and  the  needle  was 
readily  carried  around  it  and  a  No.  3  catgut  ligature  placed  in  position. 
At  this  point  of  the  operation  it  was  discovered  by  the  assistants  that  the 
pulsation  in  the  aneurysm  did  not  cease.  "We  then  discovered,  much  to  our 
disappointment,  that  the  diagnosis  as  to  the  location  of  the  aneurysm  had 
not  been  correctly  made.  Further  search  revealed  below  the  origin  of  the 
subclavian  a  rounded  mass  seemingly  not  larger  than  a  small  orange,  which 
was  pulsating.  On  discovering  this,  we  decided  that  the  ligature  upon  the 
subclavian,  being  useless,  should  be  removed.  This  having  been  accom- 
plished, the  wound  was  closed  and  the  patient  left  the  table  in  good  condi- 
tion, and  within  an  hour  he  was  conversing  freely  with  the  attendants  in 
the  ward. 

"  Patient  died  February  7,  1910,  on  rising  up  suddenly  in  bed  to  eat  his 
meal,  although  positively  ordered  not  to  make  any  sudden  exertion.  The 
postmortem  demonstrated  an  aneurysm  of  the  arch  of  the  aorta  in  its  lower 
portion,  which  had  ruptured  into  the  esophagus." 

Interested  in  the  unique  and  clever  operative  procedure  and  the  puzzling 
and  misleading  physical  signs,  I  wrote  to  Dr.  Sherrill,  who  kindly  replied 
as  follows :  "  My  case  of  ligature  of  the  left  subclavian  was  based  on  an 
incorrect  reading  of  the  skiagram  and  also  on  the  fact  that  the  pulsating 
mass  was  situated  in  the  upper  portion  of  the  left  chest  over  the  site  of  the 
subclavian  artery.  There  was  present  in  this  case  a  sacculated  aneurism  of 
the  thoracic  aorta  which  had  a  secondary  sac  extending  upward  and  for- 
ward, and  this  simulated  aneurism  of  the  subclavian.  To  produce  this 
secondary  sac  there  must  have  been  a  small  rupture  and  the  wall  of  the 
secondary  sac  was  found  to  be  made  up  of  connective  tissue." 


1 

May  not  the  fact  that  the  radial  pulse 
was  unaffected  account  in  part   for 
the   great    swelling   of   the    arm    in 
this    case    in    which    the    aneurism 
was  so  small? 

Autopsy:    The  final  haemorrhage  had 
come  from  the  subclavian  at  the  site 
of  the  ligature  which  had  cut  com- 
pletely through  the  vessel  and  had 
been     applied     distal     to     all     the 
branches   of  the   first  portion.     The 
posterior  and  suprascapular    arteries 
sprang  from  a  common  trunk  distal 
to  the  ligature.    The  original  haem- 
orrhage had  come  from  the  posterior 
scapular  which   had   been   cut   with 
the  chisel.    No  mention  is  made  of 
the  superior  intercostal  artery. 

The  case  is  so  briefly  and  indefinitely 
reported  that  one  is  not  quite  sure 
that   the   artery  was   ligated   in   its 
first   part.     The   author   states   that 
he   "  threw  a  thread   around "   this 
portion.    Fine  silk  used  for  the  liga- 
ture of  the  subclavian  was  probably 
responsible  for  the  first  haemorrhage 
if  the  operator  is  correct  in  assum- 
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and  in  sac  in  4  days  post  op.  I. 
Gradual  increase  in  size  of  aneurism. 
Hand  became  swollen ;  pain ;  im- 
pairment of  finger  motions. 

The  ligation  of  the  vertebral  and  in- 
ferior thyroid  arteries  at  the  second 
operation  did  not  arrest  the  pulsa- 
tion of  the  sac.  The  axillary  artery 
was  therefore  ligated  "  just  above  " 
the  subscapular  branch  and  there- 
upon pulsation  in  the  sac  and 
brachial  and  radial  arteries  ceased. 

This  is  the  only  aneurism  of  the  spon- 
taneous variety  on  our  list  not  cured 
by  the  ligation  of  the  subclavian. 
May  not  this  aneurism  have  been 
due  primarily  to  a  cervical  rib 
(vid.  discussion  in  text)  ? 

The  operator  probably  merely  freed 
the  last  two  cervical  pairs,  it  being 
hardly  conceivable  that  he  would 
have  resected  them.  It  is  inter- 
esting to  note  that  the  freeing  of 
the  nerves  entirely  relieved  the 
pains. 

It  would  seem  that  the  sac  should 
have  been  excised  rather  than  tam- 
poned. 

Duval  believed  that  death  was  due  to 
embolus  originating  from  clot  at  site 
of  temporary  ligation  of  carotid.  I 
am  unable  to  share  this  belief. 

Duval  very  briefly  describes  the  opera- 
tion in  a  letter  to  Schwartz. 
Whether  the  precautionary  loop 
about  subclavian  was  tied  is  not 
stated.  In  any  event  the  proximal 
ligature  must  have  been  on  the  first 
portion. 

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LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  569 

BIBLIOGRAPHY 

1.  Babinski,  J.,  and  Heitz,  J.:    Hyperthermie  locale  du  membre  superieur,  apres 

resection  d'un  anevrisme  axillaire,  chez  un  blesse  presentant  une  paralysie 
complete  du  plexus  brachial  du  meme  cote.  Bull,  et  mem.  Soc.  med.  d. 
hop.  de  Paris,  1916,  3me.  s.,  xl,  2324. 

2.  Ballance,  Sir  Charles:    A  case  of  ligation  of  the  first  part  of  the  left  subclavian 

artery.  Jour.  Roy.  Army  Med.  Corps,  Lond.,  1918,  xxxi,  417. 

3.  Ballance,  C.  A.,  and  Edmunds,  W. :   A  treatise  on  the  ligation  of  the  great  arteries 

in  continuity,  with  observations  on  the  nature,  progress  and  treatment  of 
aneurism.   London,  1891. 

4.  Banks,  Sir  William  H.:    [Unsuccessful  attempt  to  ligate  the  first  portion  of  the 

left  subclavian  artery.]    Lancet,  Lond.,  1903,  i,  103. 

5.  Bardenheuer,   B.:    Die   Verletzungen   der   oberen   Extremitaten.    Deut.   Chir., 

Stuttgart,  1886,  Lieferung  63a,  Theil  I,  p.  445. 

6.  Bean,  R.  B.:    A  composite  study  of  the  subclavian  artery  in  man.   Amer.  Jour. 

of  Anat.,  Balto.,  1905,  iv,  303. 

7.  Braithwaite,  L.  R.:    Excision  of  a  subclavian  aneurism.    Brit.  Jour,  of  Surg., 

1920,  vii,  390. 

8.  Browne,  C.  G.:    A  case  of  diffuse  traumatic  aneurism  and  ligature  of  the  first 

part  of  the  subclavian.  Brit.  Med.  Jour.,  Lond.,  1911,  ii,  1534. 

9.  Carnochan,  J.  M.:    Elephantiasis  Arabum  of  the  right  inferior  extremity,  success- 

fully treated  by  ligature  of  the  femoral  artery.  New  York  Jour.  Med.  and 
the  Collateral  Sciences,  1852,  ix,  161. 

10.  Cooper,  Sir  Astley:    Reported  in  The  London  Medical  Review,  1809,  ii,  300: 

Medical  and  Surgical  Intelligence,  Art.  2. 

Reported  by  Dr.  Mott:  Case  of  subclavian  aneurism,  which  occurred  in 
Guy's  Hospital,  London;  communicated  to  Dr.  Miller,  by  Valentine  Mott, 
M.  D.,  Corresponding  Member  of  the  Medical  Society  of  London,  etc.  The 
Medical  Repository,  N.  Y.,  1810,  third  Hexade,  vol.  i,  p.  331. 

11.  Delbet,  P.:    Anevrisme  de  la  sous-claviere  gauche.  Bull,  et  mem.  Soc.  de  Chir., 

Paris,  1910,  xxxvi,  1114. 

12.  Delbet,  P.,  and  Mocquot,  P.:    Affections  chirurgicales  de  arteres.   Being  Vol.  xi 

of  Nouveau  traite  de  chirurgie,  published  under  the  direction  of  A.  le  Dentu 
and  P.  Delbet.   Paris,  1911. 

13.  Dreist,  K.:    Ueber  Ligatur  und  Kompression  der  Arteria  iliaca  communis.    D. 

Zeit.  f.  Chir.,  Leipzig,  1904,  lxii,  5. 

14.  Diinow,  K.  F.  E. :    Durch  Exstirpation  geheilter  Fall  eines  traumatischen  Aneur- 

ysma  der  Arteria  subclavia  mit  Bemerkungen  fiber  die  operative  Behandlung 
dieser  Aneurysmen.    Inaug.-Diss.,  Heidelberg,  1904. 

15.  Duval,  P.:    Anevrisme  de  l'artere  sous-claviere  droite.   Extirpation  du  sac  apres 

resection  temporaire  de  la  clavicule.  Ligature  laterale  de  la  veine  sous- 
claviere.  Guerison.  Bull,  et  mem.  Soc.  de  Chir.,  Paris,  1910,  xxxvi,  420. 

16.  Idem:   Schwartz,  Bull,  et  mem.  Soc.  de  Chir.,  Paris,  1910,  xxxvi,  874,  1138. 

17.  Gaudiani,  V.:   Ligation  of  the  first  part  of  the  left  subclavian  for  aneurism.  Med. 

Reci  N.  Y.,  1915,  lxxxvii,  331. 

18.  Gurlt,  E.:    Geschichte  der  Chirurgie  und  ihrer  Ausubung.    Berlin,  1898. 

19.  Halsted,  W.  S.:    Ligation  of  the  first  portion  of  the  left  subclavian  artery  and 

excision  of  a  subclavioaxillary  aneurism.  Bull,  of  The  Johns  Hopkins 
Hospital,  Balto.,  1892,  iii,  93. 


570  LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY 

20.  Idem:    Clinical  and  experimental  contributions  to  the  surgery  of  the  thorax. 

Trans.  Amer.  Surg.  Assn.,  Phila.,  1909,  xxvii,  111. 

21.  Idem:   The  effect  of  ligation  of  the  common  iliac  artery  on  the  circulation  and 

function  of  the  lower  extremity.  Report  of  a  cure  of  ilio-femoral  aneurism 
by  the  application  of  an  aluminum  band  to  that  vessel.  Bull,  of  The  Johns 
Hopkins  Hospital,  Balto.,  1912,  xxiii,  191. 

22.  Idem:   A  striking  elevation  of  the  temperature  of  the  hand  and  forearm  follow- 

ing the  excision  of  a  subclavian  aneurism  and  a  part  of  the  third  portion 
of  the  left  subclavian  artery.  Bull,  of  The  Johns  Hopkins  Hospital,  Balto., 
July,  1920,  xxxi,  219. 

23.  Hamann,  C.  A.:    Ligation  of  the  abdominal  aorta:  ligation  of  the  first  portion 

of  the  left  subclavian.  Annals  of  Surgery,  Phila.,  1918,  lxviii,  217. 

24.  Jacobsthal,  H:    Beitrage  zur  Statistik  der  operativ  behandelten  Aneurysmen. 

II.  Das  Aneurysma  der  arteria  subclavia.  D.  Zeit.  f.  Chir.,  Leipzig,  1903, 
lxviii,  239. 

25.  Jiingst,  of  Saarbriicken:    Ein  geheilter  Fall  von  Unterbindung  der  Arteria  sub- 

clavia am  Aortenbogen.  Beitr.  z.  klin.  Chir.,  Tubingen,  1902,  xxxiv,  307. 
(Also  reported  by  Philipp,  J.  A.:  Unterbindung  der  Arteria  subclavia  in 
ihrem  ersten  Abschnitt  nach  Schussverletzung.  Inaug.-Diss.,  Leipzig,  1900, 
p.  17.) 

26.  Kammerer,  F.:    Ligature  of  the  first  portion  of  the  left  subclavian  artery  for 

aneurism ;  death  after  four  weeks.   Med.  Rec,  N.  Y.,  1899,  Ivi,  924. 

27.  Koch,  W.:  Ueber  Unterbindungen  und  Aneurysmen  der  Arteria  subclavia.  Arch. 

f.  klin.  Chir.,  Berlin,  1869,  x,  195. 

28.  Kohler,   A.:     Beitrage   zur  Gescbichte   der   Extirpatio   aneurysmatis.    Arch.   f. 

klin.  Chir.,  Berlin,  1906,  lxxxi,  Theil  I,  p.  333. 

29.  Lane,  L.  C:    Ligations  done  for  the  cure  of  aneurism.   Pacific  Med.  and  Surg. 

Jour.,  San  Fran.,  1883-84,  xxvi,  145. 

30.  Leriche,   R.:     Du   syndrome   sympathique    consecutif   a,   certaines   obliterations 

arterielles  traumatiques  et  de  son  traitement  par  la  sympathectomie  periph- 
erique.   Bull,  et  mem.  Soc.  de  Chir.,  Paris,  1917,  xliii,  310. 

31.  Leriche,  R.,  and  Heitz,  J.:    Resultats  de  la  sympathectomie  periarterielle  dans 

le  traitement  des  troubles  nerveux  post-traumatiques  d'ordre  reflexe  (type 
Babinski-Froment) .  Lyon  Chir.,  Paris,  1917,  xiv,  754. 

32.  Makins,  Sir  George  Henry:    Gunshot  injuries  of  the  arteries.    The  Bradshaw 

Lecture.   London,  1914. 

33.  Idem:   On  gunshot  injuries  to  the  blood  vessels.  Founded  on  experience  gained 

in  France  during  the  Great  War,  1914-1918.    New  York,  1919. 

34.  Marchesano,  V. :    Legatura  della  succlavia  fra  la  trachea  e  gli  scaleni.   L'  Osser- 

vatore  medico,  Palermo,  1875  (anno  18),  s.  3,  vol.  v,  p.  327. 

35.  Matas,  R.:    Traumatic  arterio- venous  aneurisms  of  the  subclavian  vessels,  with 

an  analytical  study  of  fifteen  reported  cases,  including  one  operated  upon. 
Jour.  Amer.  Med.  Assn.,  Chicago,  1902,  xxxviii,  103,  173,  242,  318. 

36.  Idem:    Surgery  of  the  vascular  system.    Being  Chapter  lxx  in  Keen's  Surgery, 

Phila.,  1909,  vol.  v. 

37.  Monod,  Ch.,  and  Vanvert's,  J.:    Du  traitement  des  anevrismes  arteriels.    Docu- 

ments et  remarques.   Rev.  de  Chir.,  Paris,  1910,  xli,  784,  1098;  ibid.,  1910, 
xlii,  163,  407. 
Mott,  Valentine:    Reports  Sir  Astley  Cooper's  case,  Medical  Repository,  N.  Y., 
1810.  third  Hexade,  vol.  i,  p.  331. 


LIGATION  OF  LEFT  SUBCLAVIAN  ARTERY  571 

38.  Moynihan,  B.  G.  A.:    A  case  of  subclavian  aneurism  treated  by  excision  of  the 

sac,  with  remarks  on  the  ligation  of  the  innominate  artery  and  on  the 
treatment  of  aneurism.    Annals  of  Surg.,  Phila.,  1898,  xxviii,  1. 

39.  Neff,  J.  M.:    Ligation  of  the  first  portion  of  the  left  subclavian  artery.    With 

report  of  a  recent  successful  case.  Annals  of  Surg.,  Phila.,  1911,  liv,  503. 

40.  Newbolt,  G.  P.:    A  case  of  aneurism  of  the  second  and  third  parts  of  the  left 

subclavian  artery  in  a  woman.  Brit.  Med.  Jour.,  Lond.,  1912,  ii,  867. 

41.  Norris,  G.  W.:    Table  showing  the  mortality  following  the  operation  of  tying 

the  subclavian  artery.   Amer.  Jour.  Med.  Sci.,  1845,  n.  s.  x,  13. 

42.  Oberst, :   Das  Aneurysma  der  Subclavia.   Beitr.  z.  klin.  Chir.,  Tub.,  1904, 

xli,  459. 

43.  v.  Oppel,  W.  A.:    Zur  operativen  Behandlung  der  arterio-venosen  Aneurysmen. 

Arch.  f.  klin.  Chir.,  Berl.,  1908,  lxxxvi,  31. 

44.  Osier,  Sir  William:    Remarks  on  arterio-venous  aneurism.    Lancet,  Lond.,  1915, 

i,  949. 

45.  Philipp,  J.  A.:    Unterbindung  der  Arteria  subclavia  in  ihrem  ersten  Abschnitt 

nach  Schussverletzung.  Inaug.-Diss.,  Leipzig,  1900,  p.  17.  (Reports  JUngst's 
case.) 

46.  Poland,  A.:    Statistics  of  subclavian  aneurism.    Guy's  Hosp.  Rep.,  Lond.,  1870, 

3d  s.,  xv,  47.  Statistical  report  on  the  treatment  of  subclavian  aneurism. 
Guy's  Hosp.  Rep.,  1871,  3d  s.,  xvi,  1;  1872,  3d  s.,  xvii,  1. 

47.  Propping,   K.:    Ueber   die   Ursache    der   Gangran   nach   Unterbindung   grosser 

Arterien.   Munch,  med.  Wochenschr.,  1917,  lxiv,  598. 

48.  Purmann,  Matthaus  Gottfried.   Chirurgia  curiosa,  ed.  1716. 

49.  Rodgers,  J.   K.:     Case    of   ligature    of   the  left   subclavian   artery   within   the 

scalenus  muscle,  for  aneurism.  New  York  Jour,  of  Med.  and  the  Collateral 
Sciences,  1846,  vii,  219. 

50.  Rubritius,  H.:  Die  chirurgische  Behandlung  der  Aneurysmen  der  Arteria  sub- 

clavia.  Beitr.  z.  klin.  Chir.,  Tub.,  1911,  Bd.  76,  p.  144. 

51.  Savariaud,   M.:     Le  traitement   chirurgical   des   anevrysmes   de   1' artere   sous- 

claviere.    Rev.  de  Chir.,  Paris,  1906,  xxxiv,  1. 

52.  Schopf,  F.:  Zur  Aneurysma  Behandlung.  Wiener  klin.  Wochenschr.,  1891,  iv,  840. 

53.  Schumpert,  T.  E.:    Ligature  of  the  left  subclavian  in  third  part  for  axillary 

aneurism — recovery — ligature  of  the  innominate  for  innominate  aneurism — 
also  left  subclavian  in  its  first  part  for  aneurism  of  third  part — recovery. 
Med.  Rec,  N.  Y.,  1898,  liv,  338. 

54.  Schwartz,  E.:    Enorme  anevrisme  diffus  du  cou  et  de  la  region  sous-claviculaire. 

Paralysie  du  membre  superieur  gauche.  Compression  du  recurrent  gauche. 
Bull,  et  mem.  Soc.  de  Chir.,  Paris,  1910,  xxxvi,  874;  Anevrisme  diffus  traum- 
atique  de  la  sous-claviere  gauche.    Ibid.,  p.  1138.    (Reports  Duval's  case.) 

55.  Sehrt,  E.:    Ueber  die  kunstliche  Blutleere  von  Gliedmassen  und  unterer  Korper- 

halfte,  sowie  liber  die  Ursache  der  Gangran  des  Gliedes  nach  Unterbindung 
der  Arterie  allein.  Med.  klin.,  Berlin,  1916,  xii,  1338. 

56.  Sencert,  L. :    Le  traitement  des  plaies  vasculaires  a  1'  avant.    Lyon  Chir.,  Paris, 

1917,  xiv,  640. 

57.  Sherrill,  J.  G.:    Report  of  a  case  of  aneurism,  with  a  new  method  of  ligature 

of  the  left  subclavian.  Trans.  South.  Surg,  and  Gyn.  Assn.,  Nashville,  1911, 
xxiii,  190. 

58.  Souchon,  E.:    Operative  treatment  of  aneurisms  of  the  third   portion   of  the 

subclavian  artery.   Annals  of  Surgery,  Phila.,  1895,  xxii,  545,  743. 


572  LIGATION  OR  LEFT  SUBCLAVIAN  ARTERY 

59.  Stonham,  C:    A  case  of  aneurism  of  the  second  and  third  parts  of  the  left 

subclavian  artery;  ligature  of  the  first  part;  recurrent  pulsation;  simul- 
taneous ligature  of  the  inferior  thyroid,  vertebral,  and  third  part  of  the 
axillary  arteries;  recovery.   Lancet,  Lond.,  1902,  ii,  291. 

60.  Turner,  Th.:    A  propos  des  plaies  des  arteres.    Bull,  et  mem.  Soc.  de  Chir., 

Paris,  1917,  xliii,  1469. 

61.  White,  J.  S.:    Traumatic  aneurism  of  the  left  subclavian  artery:    successful 

ligation  at  the  junction  of  the  first  and  second  portions.  Brit.  Med.  Jour., 
Lond.,  1918,  ii,  131. 

62.  Wieting,  Prof.:    Die  Unterbindung  der  A.  subclavia  sin.  in  lhrem  I.  Abschnitt. 

Zentralbl.  f.  Chir.,  Leipzig,  1912,  xxxix,  1156. 

63.  Wolff,  E.:    Die  Haufigkeit  der  Extremitatennekrose  nach  Unterbindung  grosser 
Gefassstamme.  Beitr.  z.  klin.  Chir.,  Tub.,  1908,  lviii,  762. 


A  STRIKING  ELEVATION  OF  THE  TEMPERATURE  OF  THE 
HAND  AND  FOREARM  FOLLOWING  THE  EXCISION  OF  A 
SUBCLAVIAN  ANEURISM  AND  LIGATIONS  OF  THE  LEFT 
SUBCLAVIAN  AND  AXILLARY  ARTERIES  l 

In  a  series  of  signally  interesting  papers  Prof.  Rene  Leriche  calls  atten- 
tion to  the  value  of  what  he  terms  periarterial  sympathectomy  in  the  treat- 
ment of  various  neuralgias,  local  ischemias,  reflex  contractures  of  the 
Babinski-Froment  type,  and  other  affections.  Fostered  in  the  traditions  of 
the  schools  of  Magendie,  Claude  Bernard,  and  Brown  Sequard,  it  was  in  the 
happy  order  of  things  that  it  should  fall  to  the  lot  of  a  surgeon  of  Lyon  to 
turn  to  therapeutic  account  a  discovery  of  the  greatest  of  the  founders  of 
experimental  medicine.  A  devoted  disciple  of  Jaboulay,  Leriche  credits  this 
talented  surgeon,  his  "  master,"  with  the  suggestion  which  led  to  the  novel 
and  important  researches  made  by  him  during  the  years  of  the  war. 

My  interest  in  Leriche's  work  has  been  reawakened  by  an  observation 
made  only  a  few  weeks  ago  in  the  Surgical  Clinic  of  The  Johns  Hopkins 
University.  In  1918  I  ligated  the  left  subclavian  and  carotid  arteries  near 
their  origin  from  the  aorta  for  the  cure  of  a  huge  subclavian  aneurism 
(Plate  XLIII,  1  and  2).  For  a  year  the  aneurism  decreased  steadily  in  size 
(Plate  XLIV,  1  and  2,  and  Plate  XLV,  1  and  2).  Then  for  a  year  we  lost 
track  of  the  patient.  About  two  months  ago  we  succeeded  in  tracing  him, 
and  persuaded  him  to  let  us  excise  the  aneurism,  which  in  the  period  of 
nonobservation  had  developed  a  faint  pulsation  and  become  slightly  larger 
(Plate  XL VI,  1).  About  four  hours  after  this  operation,  at  which  the 
aneurism  was  excised  and  the  subclavian  and  axillary  arteries  ligated,  it 
was  noticed  that  the  left  hand  and  forearm,  which  for  two  years  had  been 
strikingly  cold,  had  become  abnormally  warm — appreciably  warmer  than 
the  corresponding  limb.  Unfortunately,  our  surface  thermometer  had  been 
broken  and  we  were  unable  to  obtain  another.  About  five  weeks  after  the 
operation  the  hand  and  forearm  became  cold  again — at  first  in  small  areas — 
remaining  cold  for  only  a  day  or  two. 

Today  (June  28th),  the  69th  since  the  operation,  the  back  of  the  left 
hand  is  quite  cold,  whereas  the  left  palm  is  about  as  warm  as  the  right.  The 
temperature  of  the  hand  and  forearm  has  varied  from  day  to  day  and  from 
hour  to  hour;  certain  small,  quite  well-defined  areas  have  remained  uni- 

1  Johns  Hopkins  Hosp.  Bull.,  Bait.,  1920,  xxxi,  219-224.    (Reprinted.) 

38  573 


574  EXCISION  OF  SUBCLAVIAN  ANEURISM 

f  ormly  cool ;  otherwise,  the  hand  and  forearm  hare  maintained  their  normal 
warmth. 

Sur.  No.  46179.  Alexander  Miller.  Negro,  aet.  29.  Admitted  to  The 
Johns  Hopkins  Hospital  April  22,  1918 :  discharged  August  12,  1918. 

The  patier.:  states  That  he  has  always  been  perfectly  well  In  April,  1  1 ' 
he  noticed  a  swelling  about  the  size  of  an  egg  above  the  left  clavicle.  Almost 
simultaneously  with  the  recognition  of  the  swelling,  pain  and  numbness  in 
the  upper  extremity  were  observed.  The  growth  of  the  tumor  was  gradual 
until  about  March,  1918 :  since  then  it  has  been  very  rapid.  For  the  past  two 
x  the  limb  has  been  totally  paralyzed.  The  patient  recalls  that  until 
;7mas.  1917,  he  could  still  raise  his  arm  a  little. 

About  four  years  before  admission  the  patient  was  shot  just  above  the 
left  clavicle.  The  wound  healed  promptly.  The  bullet  was  not  removed  and 
has  riven  him  no  indication  of  its  presence. 

Examination. — The  patient  is  evidently  suffering  severe  pain,  and  con- 
stantly supports  his  left  wrist  with  his  right  hand.    The  pain,  he  s; 
most  intense  from  the  elbow-joint  to  the  hand  and  in  the  left  shoulder. 

A  huge  aneurism  occupies  the  left  neck  from  the  clavicle  to  the  ear 
(Plate  XLIII.  1  and  2 ) .  The  head  is  deflected  and  rotated  to  the  right.  The 
tTtz  :  :he  pulsating  mass  is  about  on  a  plumb-line  dropped  to  the  junc- 
tion of  the  middle  and  inner  thirds  of  the  clavicle.  The  swelling  and  pulsa- 
tion extend  on  to  the  chest,  and  the  whole  body  is  jarred  with  each  heartbeat. 
riorly  the  diffuse  pulsating  tumefaction  spreads  out  to  a  point  below 
the  spine  of  the  scapula.  The  aneurism  extends  upward  in  dome-shape;  a 
hand  can  be  inserted  between  it  and  the  face  down  to  the  angle  of  the  lower 
jaw.  The  whole  shoulder  girdle  appears  to  be  raised  away  from  the  chest 
wall,  the  acromioclavicular  articulation  being  apparently  disrupted.  The 
:  ver  the  tumor  is  very  tense  and  glistening.  From  the  clavicle  to  about 
the  level  of  the  nipple  the  brawny  tissues  are  probably  infiltrated  with  blood 
bD  as  inflammatory  products.  The  trachea  is  displaced  to  the  right. 
A  fvstolic  bruit,  most  distinct  above  the  inner  third  of  the  clavicle,  can  be 
heard  over  the  greater  part  of  the  pulsating  mass.  No  thrill  can  be  felt. 
The  left  radial  pulse  is  absent.  There  is  slight  ptosis  of  the  left  eyelid,  but 
the  pupils  respond  equally.  Only  the  inner  third  and  the  acromial  tip  of 
the  clavicle  can  be  denned  with  the  fingers.  The  remainder  of  the  bone  is 
buried  in  the  tumefaction.  A  bullet  is  palpable  just  beneath  the  skin  to 
the  left  and  below  the  spine  of  the  seventh  cervical  vertebra.  The  left  arm 
is  paralyzed.  The  extent  of  the  loss  of  motion  and  sensation  and  the  degree 
of  restoration  of  function  will  be  outlined  in  a  subsequent  paper. 

Fluoroscopic  Examination. — The  shadow  of  the  aneurism  extends  to  the 
lower  border  of  the  clavicle  but  not  to  the  first  rib.  The  heart  seems  not  to 
be  enlarged.  The  right  subclavian  and  carotid  arteries,  distinctly  seen,  are 
normal  in  - 

igraphic  Be  port. — Large  mass  in  left  neck.    Clavicle  deeply  eroded, 
perhaps  fragmented.  Bullet  in  upper  dorsal  region. 

Operation,  April  26,  191S.—(I)t.  Halsted.)  Ligation  of  the  left  common 
carotid  and  the  left  subclavian  arteries  near  their  origin  from  the  aorta. 


TEMPEEATUEE  OF  HAND  AND  FOEEAEM  575 

Ether.  Wide  protection  of  the  operative  field  with  celloidin-silk.2  Trans- 
verse bow-incision  just  below  the  cervicothoracic  junction,  supplemented  by 
a  vertical  one  along  the  left  border  of  the  sternum  (bow  and  plummet  inci- 
sion). Free  exposure  of  manubrium  and  left  sternoclavicular  joint.  The 
incised  tissues  were  oedematous,  particularly  so  below  the  clavicle.  The 
superficial  vessels  were  abnormally  large.  Careful  haemostasis  by  the  fine 
silk  transfixion  method.  The  left  two-thirds  of  the  manubrium  and  the  left 
sternoclavicular  joint  were  resected  with  the  giant  rongeur  forceps  of 
Esmarch,  care  being  taken  to  avoid  disturbing  the  fragments  of  the  eroded 
clavicle.  The  thymus  gland  and  the  left  innominate  vein  were  drawn  up- 
ward and  to  the  right  with  a  retractor. 

The  trachea  in  the  thorax  as  well  as  in  the  neck  was  displaced  to  the  right 
by  the  pressure  of  the  aneurism.  The  left  carotid,  deeply  situated  and 
occupying  the  midline  in  the  chest,  was  gently  occluded  with  a  tape  ligature. 
This  artery  was  thought  at  first  to  be  the  left  subclavian  inasmuch  as, 
according  to  the  erroneous  testimony  of  an  assistant,  its  occlusion  did  not 
affect  the  pulse  in  the  left  temporal  artery,  and  lessened  the  force  of  the 
pulsation  in  the  aneurism.  To  obtain  access  to  the  left  subclavian  artery  the 
cartilage  of  the  left  first  rib  and  the  adjoining  margin  of  the  sternum  were 
cut  away.  The  arch,  the  aortic  isthmus  and  descending  aorta,  and  the  left 
auricle  of  the  heart  were  palpated  with  the  finger  of  the  operator  before  the 
left  subclavian,  lying  close  to  the  vertebral  column,  was  identified.  With 
the  aid  of  four  long,  narrow  dissectors,  two  of  which  were  manipulated  by 
the  operator  and  two  by  Dr.  Mont  Eeid,  the  vessel  was  clearly  exposed  at 
its  origin  from  the  aorta  and  for  several  centimeters  distal  to  this  point. 
As  it  was  evident  that  none  of  the  various  aneurism  needles  was  suitable  for 
the  passage  of  a  ligature  at  this  depth,  a  long,  narrow,  blunt  dissector, 
slightly  curved  and  pierced  at  its  tip,  was  armed  with  fine  silk  and  passed 
under  the  artery.  By  means  of  this  thread  and  then  another,  linen  tapes 
were  drawn  under  the  subclavian ;  both  of  these  were  tied,  the  second  distal 
and  close  to  the  first,  with  force  only  sufficient  to  close  completely  the  artery's 
lumen.  The  aneurism  became  very  tense  and  hard  immediately  after  the 
ligation,  but  was  pulseless. 

The  patient's  condition,  bad  on  admission  and  particularly  so  just  before 
operation,  caused  us  some  anxiety.  Traction  within  the  thorax  on  the 
branches  of  the  aortic  arch  or  on  the  pulmonary  artery  affects  unfavorably 
and  eventually  disastrously  the  action  of  the  heart.  The  pulse,  about  120 
at  the  beginning,  was  140  +  and  quite  weak  at  the  termination  of  the  opera- 
tion. The  wound  was  completely  and  accurately  closed  with  interrupted 
sutures  of  fine  silk.  A  large  dead  space  in  the  mediastinum  was,  naturally, 
unavoidable. 

Healing  per  primam. 

November  9,  1918. — The  patient  has  been  examined  frequently  since  his 
discharge  from  the  hospital.  There  has  been  no  pulsation  in  the  aneurism 
since  the  operation.  The  mass  has  steadily  but  slowly  decreased  in  size. 
The  patient  can  make  slight  movements  with  the  left  fingers,  otherwise 

2W.  S.  Halsted.  Clinical  and  experimental  contributions  to  the  surgery  of  the 
Thorax.  Trans.  Amer.  Surg.  Assn.,  1909,  xxvii,  p.  111. 


576  EXCISION  OF  SUBCLAVIAN  ANEURISM 

there  has  been  no  appreciable  return  of  power  or  sensation  in  the  para- 
lyzed arm. 

The  patient  was  observed  frequently  throughout  the  year  following  the 
operation.  Slowly  but  steadily  the  pulseless  tumor,  during  this  period, 
diminished  in  size.  Then  for  a  year  the  patient,  living  out  of  town,  was  lost 
sight  of.  Exactly  two  years  after  the  first  operation  he  returned,  at  our 
solicitation,  to  the  hospital.  Now  for  the  first  time  since  the  operation  a  very 
faint  pulsation  was  discernible.  The  tumor  (Plate  XL VI,  1)  measured  in 
its  transverse  (frontal)  diameter  precisely  the  same  as  when  last  seen  a  year 
before;  the  anteroposterior  measurement  (sagittal),  however,  gave  an  in- 
crease of  about  4  cm.  I  decided  that  the  aneurism  should  be  excised,  and 
on  the  20th  of  April,  1920,  performed  the  operation  as  follows : 

The  skin  over  the  tumor  and  a  wide  area  about  it  were  protected  with 
Chinese  silk  dipped  in  celloidin.  The  incision,  made  through  the  tightly 
adherent  silk,  ran  with  the  clavicle  in  its  central  part,  curving  up  into  the 
neck  at  its  inner  end,  and  down  along  the  cephalic  vein  at  its  outer.  Super- 
imposed on  and  not  attached  to  the  greatly  broadened  and  thickened  clavicle 
was  a  sharply  convex  bow  of  bone  about  9  cm.  long  and  6  mm.  thick.  This 
bow,  recognizable  in  the  photograph  (Plate  XLV.  1).  was  cut  away  and 
the  clavicle  bitten  through  with  a  heavy  rongeur  forceps  at  two  points  as 
close  to  the  aneurism  as  possible.  The  cephalic  vein  was  divided,  and  the 
axillary  artery — pulseless,  reduced  in  size,  but  not  empty — was  ligated  about 
at  the  junction  of  its  first  and  second  portions,  through  a  split  made  in  the 
pectoralis  minor  muscle;  the  third  portion  of  the  subclavian  artery  was 
ligated  above  the  clavicle;  the  aneurismal  sac,  and  the  resected  rib  were 
excised  in  one  piece.  The  aneurism  was  matted  almost  even-where  to  the 
surrounding  parts  by  dense  connective  tissue,  and  hence  had  to  be  carved  out 
rather  than  enucleated.  The  identification  and  freeing  of  the  roots  of  the 
brachial  plexus,  which  were  in  places  embedded  in  the  wall  of  the  sac,  con- 
sumed much  time.  The  operation  was  conducted  in  a  bloodless  manner  until 
nothing  remained  to  be  done  except  to  divide  the  narrow  neck  of  the  sac. 
The  tissues  of  this  neck  proved  to  be  thin  and  friable,  and  the  patient  lost 
a  few  cubic  centimeters  of  blood  through  the  slit  in  the  artery — the  mouth  of 
the  false  sac — which  was  readily  closed  with  three  stitches  of  fine  silk.  The 
wound  was  closed  without  drainage.  I  am  greatly  indebted  to  Dr.  Heuer 
and  Dr.  Reid  for  their  skilful  and  highly  competent  assistance  which  enabled 
me  without  concern  to  conduct  the  operation  to  a  satisfactory  conclusion. 

At  the  first  dressing,  made  on  the  10th  day  after  operation,  it  was  noted 
that  a  little  fluid  had  accumulated  in  the  outer  part  of  the  wound.  This 
was  evacuated  by  puncture  with  a  wooden  toothpick  wrapped  with  a  few 
fibres  of  cotton  dipped  in  pure  carbolic  acid.  Closure  of  the  puncture  was 
prevented  by  the  reapplication  of  the  acid  in  the  same  manner  on  two  alter- 
nate days.  The  introduction  of  a  drain  of  any  kind  we  scrupulously  avoid. 
The  word  "  drainage-tube  "  is  in  disfavor  in  our  clinic.  Should  a  wound 
become  infected,  tubes  would  be  properly  introduced  for  the  purpose  of  dis- 
infection, but  not  for  drainage. 


TEMPERATURE  OF  HAND  AND  FOREARM  577 

Noteworthy  is  the  fact  that  the  patient's  hand  and  forearm,  which  prior 
to  and  ever  since  the  first  operation  had  been  markedly  cold,  became  strik- 
ingly warm  about  4  hours  after  the  second  operation  and  have  remained 
warm,  except  in  certain  areas,  to  the  present  time  (June  28th).  It  is  im- 
probable that  the  ligation  of  the  cephalic  vein  was  in  any  part  responsible 
for  this  indubitable  improvement  in  the  circulation.  The  elevation  of  the 
temperature  of  the  hand  and  forearm  must,  I  believe,  be  attributable  to 
vasodilatation  incident  to  the  ligations  of  the  subclavian  and  axillary 
arteries — to  the  crushing  of  their  nerves.  This  question  will  be  discussed 
in  the  course  of  the  consideration  of  the  treatment  of  subclavian  aneurisms 
in  a  paper  about  to  appear  in  The  Johns  Hopkins  Hospital  Reports. 

I  have  found  pleasure  in  translating  one  of  the  papers  of  Monsieur  Leriche, 
believing  that  his  work  on  periarterial  sympathectomy  will  at  this  moment 
particularly  interest  surgeons  who  may  have  the  opportunities  and  the 
inclination  to  verify  his  observations.  While  disclaiming  unqualified  accep- 
tance of  some  of  his  explanations  and  deductions  which  are  at  variance  with 
the  teachings  of  physiologists,  we  must  recognize  that  Leriche's  contribu- 
tions are  of  unusual  interest  and  value ;  they  will  stimulate  investigation. 

PERIARTERIAL  SYMPATHECTOMY  AND  ITS  RESULTS 
Rene  Leriche 

In  January,  1916,  and  in  April  of  the  same  year,8 1  made  known  the  first 
results  which  the  denudation  and  excision  of  the  sympathetic  plexuses  around 
the  arteries  in  causalgia  and  in  certain  trophic  troubles  had  given  me.  Since 
then  this  operation  has  been  tried  in  various  ways.  Le  Fort,  Cotte,  Sencert, 
Lavenant,  de  Massary  and  Veau,  Prat,  have  reported  experiences  with  it. 
I  personally  have  performed  it  37  times.4  The  moment  seems  to  have  come 
to  indicate  briefly  the  essential  facts  which  the  procedure  has  taught  me. 
Elaborating  the  idea  of  Jaboulay,  we  must  indeed  develop  a  true  and  gen- 
eral operative  method  susceptible  of  very  varied  applications. 

I  think  at  the  outset  that  it  ought  to  be  designated  by  an  exact  name: 
it  is  a  peripheral  sympathectomy  which,  according  to  the  level  where  it  is 
practised,  ought  to  be  called  axillary  sympathectomy,  brachial,  iliac, 
femoral,  etc. 

I.  Technique. — In  order  to  achieve  it,  it  is  necessary  to  uncover  the 
artery  by  the  classic  procedure,  open  with  the  bistoury  the  cellular  sheath, 
separate  the  artery  for  8  to  10  cm.,  get  hold  of  the  inner  sheath  directly  on 
the  vessel  wall,  incise  it,  pull  one  of  the  lips  thus  made  with  a  forceps,  free 
it  either  with  the  bistoury  or  with  the  grooved  probe,  completely  stripping 

3R.  Leriche:  De  la  causalgie  envisaged  comme  une  nevrite  du  sympathetique  et 
de  son  traitement  par  la  denudation  et  1'  excision  des  plexus  nerveaux  peri-arteriels. 
Societe  de  Neurologie,  6  Janvier  1916;  La  Presse  medicale,  20  Avril  1916. 

*  More  exactly,  I  have  done  30  sympathectomies  by  denudation  and  7  times 
complete  sympathectomy  by  resection  of  a  segment  of  obliterated  artery. 


578  EXCISION  OF  SUBCLAVIAN  ANEUEISM 

the  artery  of  all  the  cellular  tissue  that  adheres  to  it.  More  or  less  easily 
according  to  the  cases,  one  is  able  thus  to  strip  the  artery,  to  decorticate  a 
fold ;  thin,  to  be  sure,  but  often  thicker  than  one  might  expect.  At  a  certain 
moment  one  has  the  impression  that  one  is  going  to  tear  the  wall  of  the 
artery ;  but  if  one  proceeds  gently  and  carefully,  guided  by  the  point  of  the 
bistoury  or  probe,  the  freeing  process  can  be  carried  on  without  risk  of  injur- 
ing the  vessel.  Only  twice  have  I  had  the  annoyance  of  making  a  small 
tear  in  the  artery ;  the  accident  was  without  serious  results.  In  case  of  neces- 
sity one  would  frankly  resect  the  segment  of  the  tear  and  tie  the  two  ends, 
accomplishing  thus  by  the  same  act  a  complete  sympathectomy.  Sometimes 
the  forceps  removes  only  rather  short  cellular  fragments,  at  other  times  one 
removes  quite  definite  laminae,  and  the  movement  of  freeing  recalls,  on  a 
small  scale,  the  subserous  decortication  of  an  inflamed  appendix,  but  one 
never  succeeds  in  removing  a  continuous  layer;  it  is  necessary  to  repeat  the 
attempt  several  times  and  with  perseverance  to  catch  the  sheath  again,  to 
remove  thin  meshes,  and  not  to  stop  until  one  has  really  the  feeling  of 
having  removed  everything.  Moreover,  one  can  verify  what  has  been  done 
by  wetting  the  wound  with  a  tampon  soaked  with  very  warm  serum:  the 
artery  takes  on  then  a  whitish  appearance,  looks  as  though  made  of  felt, 
and  one  sees  very  clearly  whether  there  remains  still  some  cellular  debris 
more  or  less  detached. 

In  the  course  of  the  cellular  decortication  it  is  necessary  to  be  careful  to 
expose  the  collateral  branches  and  guard  against  tearing  them.  This  happens 
sometimes ;  by  using  then  a  forceps  and  a  ligature  of  00  catgut  one  repairs 
this  accident  without  injury  to  the  artery.  In  addition  to  the  tears,  which 
cause  a  spurt  of  pure  blood,  there  may  be  oozing  from  the  tearing  of  the 
vasa  vasorum. 

II.  The  Physiological  Eeaction. — The  operation  thus  done  is  a 
physiological  operation ;  I  mean  to  say  by  this  that  it  is  inevitably  followed 
by  a  characteristic  physiological  reaction,  which  may  be  regarded  as  the 
test  of  the  operation;  as  there  are  characteristic  signs  of  the  section  of  the 
trunk  of  the  sympathetic  in  the  neck,  so  there  are  characteristic  signs  of  the 
section  of  the  periarterial  sympathetic  nerves.  If  these  are  wanting,  the 
operation  has  been  attempted  but  not  accomplished. 

The  results  of  our  studies  of  these  signs  Heitz  and  I  have  reported  to  the 
Societe  de  Biologie ; 6  they  are  as  follows : 

Primary  Sign. — When  one  touches  the  sympathetic  sheath,  the  artery  con- 
tracts ;  it  is  reduced  progressively  in  size  to  the  point  where  it  is  not  more 
than  a  third  or  even  a  fourth  the  normal  size  throughout  the  whole  extent 
of  the  denuded  segment.  The  segments  on  both  sides  maintain  their  normal 
size  provided  the  operation  has  not  injured  them.  The  phenomenon  is  more 
or  less  rapid  according  to  the  case ;  certain  individuals  appear  to  have  more 
irritable  sympathetic  nerves  than  others;  their  arteries  diminish  in  size 
at  the  first  touch ;  with  some  the  contraction  is  sluggish.  One  cannot  yet  give 
the  real  reason  for  these  variations.  Furthermore,  the  contraction  is  more 
marked  in  the  brachial  than  in  the  axillary  and  the  subclavian ;  it  is  slower 

8  Leriche  and  Heitz :  Des  effets  physiologiques  de  la  sympathectomie  peripherique 
reaction  thermique  et  hypertension  locales).  C.  R.  de  la  Soc.  de  Biol.,  20  Janvier, 
1917. 


TEMPEEATUEE  OE  HAXD  AND  FOBEABM  579 

in  the  femoral  than  in  the  brachial,  and  less  intense  in  the  common  iliac 
than  in  the  femoral.  In  a  word,  the  contraction  is  stronger  in  the  arteries 
of  small  size  than  in  the  large  trunks. 

This  arterial  contraction  habitually  causes  the  pulse  to  disappear,  but  it 
does  not  altogether  interrupt  the  circulation. 

Secondary  Signs. — In  the  following  hours  the  pulse  is  imperceptible  or 
very  feeble  and  the  limb  is  colder  than  the  other.  Then  little  by  little,  at 
the  end  of  three  hours,  six  hours,  and  most  often  twelve  or  fifteen  hours, 
there  appears  the  characteristic  physiological  reaction,  the  establishing  of 
which  ought  to  be  exacted  as  proof  that  suppression  of  the  sympathetic 
nerves  has  been  properly  done. 

This  reaction  is  characterized  by  an  elevation  of  the  local  temperature 
reaching  to  2°  and  even  3°  [centigrade],  by  the  elevation  of  the  arterial 
pressure,  and  by  the  augmentation  in  the  amplitude  of  the  oscillations  of 
Pachon.  M.  Heitz,  who  with  his  very  special  competence  has  established 
these  facts  many  times  on  my  patients,  has  found  that  the  increase  in  pres- 
sure could  be  as  much  as  4  cm.  of  mercury  in  comparison  with  the  healthy 
side  (method  of  Eiva  Eocci) ;  it  is  a  detail  worthy  of  mention  that  analogous 
figures  were  noted  by  Claude  Bernard  in  his  investigations  of  the  cervical 
sympathetic  nerves. 

This  vasodilator  reaction  is  only  temporary :  the  hyperthermia,  the  rise  in 
pressure,  and  the  increase  in  amplitude  of  the  oscillations  diminish  little 
by  little;  sometimes  as  early  as  the  loth  day  and  usually  at  the  end  of  a 
month  one  finds  it  no  more.  On  the  other  hand,  in  some  cases  in  which  I 
have  performed  sympathectomy  on  the  brachial  or  the  subclavian  artery  by 
resecting  totally  the  obliterated  arterial  cord,  the  elevations  of  temperature 
have  been  more  lasting  than  in  the  cases  in  which  a  sympathectomy  by 
denudation  alone  was  done.  This  is  comprehensible,  for  the  operation  is 
more  complete — the  sympathectomy  being  necessarily  total.  Classed  with 
these  observations  should  be  one  made  by  M.  Babinski  and  M.  Heitz :  four 
months  after  the  extirpation  of  an  axillary  aneurism  the  hand  on  the  side 
operated  on  was  frequently  warmer  than  that  on  the  healthy  side.  This 
phenomenon,  apparently  paradoxical,  is  understood  very  well  when  one  con- 
siders that  the  ablation  of  a  sac  is  in  reality  a  total  sympathectomy. 

III.  The  Lessons  Fuexished  by  the  Operation*. — Observation  of 
series  of  operations  and  analysis  of  the  therapeutic  results  permit  interesting 
deductions  from  physiological  and  pathological  points  of  view. 

1.  From  the  Physiological  Point  of  Yiev:. — Two  facts  become  clear:  The 
vasomotor  phenomena  which  Heitz  and  I  have  studied  under  the  name  of 
vasodilator  reaction  permit  us  to  isolate  the  paths  along  which  certain  vaso- 
constrictive acts  are  conducted  and  to  establish  their  correct  value. 

But  there  is,  above  all,  this  one :  it  seems  to  follow  from  certain  observa- 
tions that  the  voluntary  muscular  contraction  is,  in  a  certain  sense,  very 
dependent  on  the  sympathetic  nerves.  The  integrity  of  the  motor  nerve  and 
of  the  muscle  are  not  sufficient  to  insure  the  proper  accomplishment  of  the 
movement  that  is  commanded.  If  the  sympathetic  nerve  is  affected  at  a 
distance  or  if  it  does  not  act  normally,  the  muscle  becomes  hard,  and  con- 
tracts, and  the  will  is  powerless  to  relax  or  contract  it.  Xow  in  these  cases 
sympathectomy  lifts  the  barrier  and  makes  possible  the  progressive  repara- 
tion of  the  voluntarv  movements.  La  the  case  of  wounded  men  having  reflex 


580  EXCISION  OF  SUBCLAVIAN  ANEUEISM 

contractions  of  the  Babinski-Froment  type,  with  fingers  twisted,  motionless, 
incapable  of  movement,  it  has  been  sufficient  to  modify  the  vasomotor  inner- 
vation to  see  a  certain  degree  of  voluntary  motion  appear  again  the  follow- 
ing day. 

This  fact  which  M.  Heitz  *  and  I  have  confirmed  several  times  has  a  real 
physiological  bearing.  What  we  now  know  of  muscle  innervation  in  man 
does  not  lead  us  to  suppose  that  it  is  a  matter  of  a  directly  muscular  action. 
It  appears,  until  we  have  made  further  inquiry,  that  the  vasomotor  phe- 
nomena alone  are  concerned  in  it,  and  a  fact  which  would  tend  to  prove  this 
is  that  the  return  of  motility  coincides  with  the  appearance  of  the  post- 
operative vasodilator  reaction  (that  is  to  say,  the  warming  up  of  the  muscle, 
its  new  circulatory  system),  and  follows  the  course  of  it. 

Sympathectomy,  furthermore,  would  appear  to  establish  the  fact  that  the 
sympathetic  nerve  is,  in  man,  the  excitosecretory  nerve  of  the  sweat  glands ; 
I  have  seen  profuse  sweating  of  the  hand  disappear  after  sympathectomy. 
The  nerve  probably  also  influences  the  growth  of  the  nails  and  the  trophicity 
of  the  skin,  since  trophic  phenomena  disappear  rapidly  after  sympathec- 
tomy. The  nerves  of  the  cerebrospinal  system,  from  this  point  of  view,  are 
probably  only  the  vectors  of  the  sympathetic. 

2.  From  the  Point  of  View  of  Pathological  Physiology. — Sympathectomy 
is,  in  certain  cases,  a  true  method  of  experimental  analysis  for  the  interpre- 
tation of  certain  complex  phenomena. 

It  demonstrates :  (a)  The  true  mechanism  of  the  production  of  dry  wounds 
of  the  arteries.  Spontaneous  haemostasis,  when  an  artery  is  divided  or 
destroyed  by  a  projectile,  is  certainly  greatly  facilitated  by,  if  it  is  not 
entirely  due  to,  the  contraction  of  the  artery  which  follows  the  destruction 
of  its  sympathetic  nerve.  It  may  be  compared  to  the  considerable  diminu- 
tion of  calibre  which  is  observed  after  sympathectomy.  Since  a  brachial 
artery  is  reduced  to  the  size  of  a  radio-palmar  or  a  digital  when  its  sympa- 
thetic nerve  is  excised,  it  is  easy  to  comprehend  how  spontaneous  haemostasis 
is  possible  after  certain  wounds  of  the  arteries  which  are  inevitably  accom- 
panied by  tearing  of  the  sheath. 

(b)  The  real  nature  of  certain  causalgias,  if  not  of  all.  As  I  demon- 
strated to  the  Societe  de  Neurologie,  in  January,  1916,  one  can  cure  obsti- 
nate causalgias  by  excising  the  involved  sympathetic  nerve.  This  observation 
proves  the  sympathetic  origin  of  the  violent  pains  which  accompany  certain 
wounds  of  nerves.  In  these  cases  the  pain  phenomena  are  not  due  to  the 
nerve  lesions,  but  to  the  lesions  of  the  neighboring  sympathetic  nerve  (the 
perivascular  sympathetic  of  the  brachial)  or  of  the  intranerve  sympathetic 
(the  sympathetic  carried  to  the  median,  for  example,  by  its  particular 
artery).  This  explains  the  fact  demonstrated  by  M.  Pierre  Marie,  M.  Miege 
and  Mme.  Benisty  that  the  pain  in  these  nerve  wounds  is  a  kind  of  reaction 
peculiar  to  the  nerves  which  have  an  artery  of  their  own  or  which  are  close 
to  a  large  artery.  This  fact  is  now  admitted  by  the  neurologists. 

(c)  The  very  great  role  of  the  sympathetic  in  the  production  of  the  reflex 
contractions  of  Babinski-Froment.   Let  us  pay  attention  to  the  character- 

'Leriche  and  Heitz:  Influence  de  la  sympathectomie  peri-arterielle  ou  de  la  re- 
section d'  un  segment  arteriel  oblitere  sur  la  contraction  volontaire  des  muscles. 
Societe  de  Biologie,  17  Fevrier,  1917. 


TEMPERATURE  OF  HAND  AND  FOREARM  581 

istics  of  this  tj-pe  about  which  there  is  so  much  confusion.  I  speak  now  of 
the  true  Babinski-Froment  type,  that  in  which  the  vasomotor  and  thermic 
phenomena  are  associated  with  motor  disturbances  and  with  modifications 
of  the  mechanical  excitability  of  the  muscles. 

In  the  cases  of  this  kind,  studied  by  M.  Babinski  or  by  his  assistants 
Froment  and  Heitz,  I  have  seen  with  Heitz  motor  disturbances  disappear 
almost  completely  after  sympathectomy.  From  the  day  following  the  opera- 
tion, when  the  vasodilator  reaction  was  very  well  established,  the  mobility 
returned  markedly  in  hands  fixed  immutably  in  position,  contracted,  the 
fingers  being  bent  into  the  palms,  or  else  turned  back  on  the  dorsal  side. 
I  am  inclined  to  believe  that  a  number  of  these  severe  cases  are  referable 
to  disturbances  of  sympathetic  origin,  caused  by  the  imprisonment  of  the 
nerve  ends  in  a  hard  and  compressing  cicatrix. 

(d)  The  role  of  the  sympathetic  in  the  production  of  certain  griff es 
cubitales.  After  brachial  sympathectomy  I  have  seen  a  loosening  up  of  a 
very  rigid  griff e  cubitale  which  had  resisted  resection  and  suture  of  the  nerve 
divided  in  the  forearm. 

I  have  made  this  observation  only  once,  but  the  phenomenon  was  per- 
fectly definite.  It  seems  to  me  that  the  observation  should  be  recorded 
because  of  its  therapeutic  interest. 

(e)  The  role  of  the  sympathetic  in  the  explanation  of  those  motor 
paralyses,  more  or  less  complete,  which  follow  certain  arterial  lesions.  When 
the  nerves  have  not  been  disturbed,  we  call  it  ischaemic  paralysis,  giving  to 
this  appellation  an  entirely  different  sense  from  that  which  we  have  in  mind 
for  the  isolated  contracture  of  the  flexors  of  Volkmann.  In  the  cases  de- 
scribed by  MM.  Dejerine  and  Tinel  there  is  rather  complete  motor  paralysis 
with  the  reaction  of  degeneration,  yet  the  nerves  were  not  divided.  The 
paralysis  coincides  with  an  oedematous  infiltration  of  the  hand  with  marked 
vasomotor  disturbances  which  lead  to  true  fibrous  transformation  of  the 
hand.  At  the  end  of  some  weeks  the  oedema  begins  to  diminish,  the  tendons 
and  the  aponeuroses  are  ensheathed  in  a  veritable  fibrous  envelope;  the 
muscles,  already  hard  and  tense,  retract  and  take  on  a  ligneous  consistency. 
In  this  picture  is  seen  the  mark  of  the  sympathetic ;  and  in  doing  S3onpa- 
thectomy  in  these  cases  M.  Heitz  and  I  have  seen  vasomotor  disturbances 
disappear,  trophic  disturbances  improve,  the  tendons  and  the  muscles  become 
on  palpation  sensibly  more  supple,  and  the  muscles  execute  slight  move- 
ments. In  one  case,  although  before  operation  there  had  been  complete 
degenerative  reaction,  four  months  after  operation  we  observed  a  very 
definite  amelioration  of  the  electric  reactions,  and  we  are  hoping  for  a 
marked  functional  recuperation. 

I  do  not  wish  to  say  that  sympathectomy  cures  the  patients;  and  it  is 
impossible  that  it  should  cure  them  at  once  when  one  considers  their 
wounds.  Unhappily,  there  is  no  cure,  but  to  me  it  appears  to  have  caused 
the  disappearance  (at  least  momentarily)  of  the  stiffness  of  the  muscles 
and  tendons ;  it  has  assured  a  manifest  suppling  up  of  muscles  which,  after 
the  sympathectomy,  executed  movements  equivalent  to  one  half  the  normal. 
Referring  to  the  fact  mentioned  above  a  propos  of  griff e  cubitale,  I  have  the 
impression  that  the  sympathetic  has  an  enormous  influence  on  the  evolution 
and  production  of  fibrous  tissue.  The  sclerous  evolution  is  modified,  it 
appears,  when  a  vasodilator  reaction  is  brought  about.  Whence  the  conclusion 


582  EXCISION  OF  SUBCLAVIAN  ANEURISM 

that  the  sympathetic  plays  probably  a  large  role  in  the  mechanism  of  the 
so-called  ischaemic  paralyses  "where  the  predominating  feature  has  not  the 
mark  of  ischaemia.  I  do  not  mean  to  say  that  the  circulatory  suppression 
caused  by  the  arterial  lesion  does  not  play  any  part,  that  would  be  absurd; 
what  I  would  say  is  that  something  more  is  involved.  But  these  cases  are 
too  rare  in  general  surgical  practice  for  me  to  follow  the  analysis  alone. 

(f )  The  role  of  the  sympathetic  in  the  production  of  heel  sloughs  in  the 
course  of  medullary  lesions.  In  one  patient  who  had  had  flabby  incomplete 
paralysis  of  the  lower  limbs  with  absence  of  reflexes,  and  incontinence  of 
urine,  there  were  two  sloughs,  one  on  the  heel,  the  other  on  the  little  toe. 
They  resisted  all  treatment.  Three  months  after  the  wound  had  been 
received,  a  femoral  sympathectomy  was  done.  Three  days  later  the  ulcera- 
tion of  the  toe  was  dry  and  cicatrized ;  that  of  the  heel,  which  was  as  large 
as  a  small  palm  of  the  hand,  diminished  in  size  and  was  covered  with  active 
granulations.   In  thirty-five  days  it  was  completely  cicatrized. 

3.  From  the  Therapeutic  Point  of  View. — I  have  tried  sympathectomy  in 
a  great  variety  of  cases,  and  it  is  rather  difficult  for  me  to  analyse  the  results, 
because  there  were  often  complex  situations  to  be  dealt  with.  Schematically, 
I  have  tried  to  influence  the  element  of  pain,  the  element  of  reflex  contrac- 
tion with  vasomotor  disturbances,  and  the  trophic  element.  In  all  the  cases 
I  have  had  failures  and  disappointments. 

I  have  done  sympathectomy  eleven  times  for  phenomena  of  pain;  once 
the  vasodilator  reaction  failed.  This  operation  was  badly  done  and  I  elimi- 
nate it.  For  the  ten  others,  six  times  there  were  true  causalgias,  and  three 
times  phenomena  of  pain  more  or  less  intense. 

For  causalgia  I  operated  four  times  on  the  upper  extremity,  twice  on  the 
lower  limb.  The  four  cases  in  the  upper  extremity  resulted  as  follows :  One 
complete  failure  (patient  operated  on  in  the  service  of  M.  Gosset),  two 
excellent  results  (complete  suppression  of  the  pains,  total  transformation 
of  the  patients)  with  final  cure,  now  dating  back  19  and  16  months.  These 
two  patients  have  been  discharged,  and  are  earning  their  living  exclusively 
by  their  own  work. 

In  a  fourth  case,  which  was  very  serious,  I  had  found  the  brachial  artery 
obliterated.  I  had  not  at  the  time  thought  that  there  would  be  any  advan- 
tage in  resecting  the  obliterated  segment.  I  performed  then  a  sympathec- 
tomy by  denudation.  The  patient  was  much  improved;  he  who  for  months 
had  been  confined  to  his  bed  with  a  wet  cloth  on  his  hand,  apprehensive, 
indifferent  to  everything  except  his  pain,  got  up  and  submitted  to  the  same 
regime  as  his  comrades ;  but  some  pains  persisted.  In  order  to  improve  these 
I  again  took  the  patient  under  my  care  and  resected  the  obliterated  arterial 
segment,  whereupon  the  persisting  disturbances  almost  completely  vanished ; 
this  result  promises  to  be  permanent.7 

In  the  lower  limb  I  did  one  femoral  sympathectomy,  with  appreciable 
amelioration.  At  a  second  operation  I  resected  the  sciatic  artery  and  the 
artery  of  the  sciatic  nerve,  with  manifest  result,  but  the  cure  has  not  been 
complete.    The  patient,  who  has  been  followed  for  six  months,  is  entirely 

T  In  one  of  the  last  Bulletins  of  the  Societe  de  Chirurgie  a  very  interesting  observa- 
tion by  M.  Le  Jemtel  is  reported,  which  shows  well  the  role  of  the  sympathetic  in  the 
paretic  syndrome  following  an  obliteration  of  the  brachial. 


TEMPERATURE  OF  HAND  AND  FOREARM  583 

relieved  at  certain  times,  but  has  suffered  much  at  others  in  damp  weather. 
His  general  condition  is  transformed.  For  those  who  know  the  lamentable 
condition  of  degeneration  of  these  patients  caused  by  their  martyrdom  of 
pain,  the  words  "  great  amelioration  "  have  a  real  significance.  This  expres- 
sion should  not  be  taken  as  a  euphemism  masking  a  failure. 

In  another  case  I  did  a  common  iliac  sympathectomy,  which  resulted  in 
great  improvement  [grande  amelioration]  with  complete  transformation  of 
the  general  condition.  The  patient  has  suffered  at  certain  times,  but  his  days 
of  respite  have  been  greater  in  number  than  his  days  of  pain.  This  is  also, 
to  my  thinking,  a  success  worth  trying  for. 

For  all  "  causalgiques  "  the  question  is  complex  in  other  ways :  these 
patients  have  a  psychology  of  their  own;  it  is  necessary  to  isolate  them 
somewhat  and  to  exercise  over  them  a  little  authority  if  we  desire  to  cure 
them.  Besides,  they  are  extremely  sensitive  to  atmospheric  changes,  and  it 
seems  as  if  their  whole  vasomotor  system  were  out  of  equilibrium.  One  local 
operation  could  not  pretend  to  set  all  this  right  at  once,  and  these  patients 
should  not  be  regarded  exactly  as  others. 

I  have  operated  four  times  for  phenomena  of  pain  accompanying  nerve 
lesions  or  arterial  obliterations.  I  had  three  excellent  results  and  one  com- 
plete failure. 

To  sum  up,  in  the  treatment  of  the  phenomena  of  pain,  sympathectomy 
cures  entirely  certain  patients,  acts  very  favorably  in  the  majority  of  cases, 
but  does  not  succeed  always  or  always  give  an  absolutely  perfect  result. 

Five  sympathectomies  for  trophic  ulcerations,  with  or  without  phlyctenae 
in  the  neighborhood,  gave  success  five  times. 

I  have  operated  three  times  for  large  bluish  oedemas  of  the  limbs,  with 
one  complete  success ;  one  great  improvement,  followed  at  the  end  of  several 
months  by  complete  cure ;  one  incomplete  result  with  partial  return  (in  the 
lower  limb),  but  on  the  whole,  amelioration. 

For  reflex  disturbances,  eighteen  sympathectomies  among  the  patients 
examined  heretofore  (except  two)  either  by  M.  Babinski,  or  by  his  assistants 
M.  Froment  and  M.  Heitz,  and  all  followed  up  by  M.  Heitz,  have  resulted 
as  follows :  * 

Three  cures,  practically  complete,  traced  for  several  months,  with  disap- 
pearance of  the  vasomotor  disturbances  and  of  the  contraction ; 

Ten  ameliorations  more  or  less  considerable,  some  of  which  were  almost 
cures ; 

Two  ameliorations  followed  by  incomplete  return  in  patients  who  had 
not  received  any  postoperative  treatment.  In  the  two  cases  the  lasting 
benefit  has  been  real ; 

One  case  in  which  the  operation,  after  failure  of  all  other  treatments,  has 
been  followed  by  the  execution  of  voluntary  movements;  also,  thanks  to 
treatment  followed  regularly  under  the  direction  of  M.  Heitz,  motility  is 
returning  little  by  little; 

Two  complete  failures.  In  these  two  patients  there  had  been  after  opera- 
tion a  beginning  return  of  voluntary  motility,  but  the  therapeutic  result  has 
been  practically  nil. 

"The  observations  will  be  published  in  extenso  in  the  August  number  of  Lyon 
chirurgical,  under  the  following  title :  Resultats  de  la  sympathectomie  peri-arterielle 
dans  le  traitement  des  troubles  nerveux  post-traumatiques  d'  ordre  reflexe. 


584  EXCISION  OF  SUBCLAVIAN  ANEURISM 

In  all  the  patients  who  have  been  really  benefited  by  the  operation  (16) 
the  vasodilator  reaction  has  been  followed  by  a  diminution  of  the  contrac- 
tion and  by  a  reappearance  more  or  less  complete  of  the  voluntary  move- 
ments. In  some  cases  the  result  has  been  surprising :  from  the  day  follow- 
ing operation  the  patients  were  able  to  make  movements  which  had  been 
impossible  for  months.  But  at  the  end  of  two  or  three  weeks,  as  the  vaso- 
dilator reaction  subsided,  the  contraction  shows  signs  of  beginning  anew 
and  the  movements  diminish  in  amplitude.  Observing  this,  we  thought, 
with  M.  Heitz,  that  the  maintenance  of  heat  in  the  member  operated  upon 
was  indicated.  For  this  purpose  M.  Heitz  has  made  my  patients  take  baths 
of  paraffine  at  60°  for  about  one  half  hour.  By  associating  with  this  treat- 
ment massage  and  reeducation  Heitz  has  obtained  very  interesting  results, 
which  permit  us  to  speak,  in  certain  cases,  of  true  cure. 

Briefly,  then,  in  the  grave  forms  of  the  syndrome  of  Babinski-Froment 
sympathectomy  by  itself  does  not  suffice.  But  without  it,  the  treatment 
usually  applied  soon  ceases  to  influence  the  condition,  and  the  result  becomes 
stabilized;  the  operation,  like  so  many  other  operations  upon  the  nervous 
system,  leaves  room  for  and  facilitates  reeducation,  and  gives  to  it  its  efficacy. 
It  is  only  one  phase  of  the  treatment,  but  it  is  a  very  rewarding  phase. 
I  insist  on  this  point  so  that  we  shall  not  expose  ourselves  to  failures  all  the 
more  bitter  when  the  operation  at  the  outset  promised  to  yield  a  brilliant 
result.  And  I  recall  what  Heitz  has  recently  written :  °  it  is  the  mixed 
method  (operation  on  the  sympathetic  followed  by  the  treatment  indicated 
above )  which  has  given  in  the  service  of  M.  Babinski  the  best  results. 

For  the  paralyses  connected  with  vascular  obliterations,  associated  or  not 
with  nerve  lesions,  sympathectomies  have  improved  the  condition  without 
giving,  except  in  one  case,  a  true  functional  result.  In  such  case  the  sympa- 
thectomy should  be  done  to  modify  the  vascularization  of  the  paralyzed 
segment,  to  check  the  fibrous  regression  of  the  muscles.  It  cannot  constitute 
of  itself  a  sufficient  treatment,  but  it  has  appeared  to  me  to  be  interesting 
and  useful.    The  future  will  determine  its  indication. 

It  is  the  same  in  regard  to  the  value  of  sympathectomy  associated  with 
operations  upon  the  nerves  in  cases  of  rebellious  contracture  of  the  median 
or  of  the  ulnar  nerve  variety.  One  cannot  say  definitely,  but  the  question 
appears  to  me  to  merit  consideration.10 

In  order  to  estimate  the  results  of  sympathectomy,  I  have  striven  to  be 
as  concrete  as  possible :  I  have  appraised  as  nil  any  result  which  was  without 
value  for  the  patient.  The  verdict  may  perhaps  appear  to  be  very  reserved. 
Truly,  I  believe  that  the  operation  is  a  very  interesting  one  and  a  useful 
expedient  to  which  one  may  resort  in  cases,  very  diverse,  which  have  been 
irresponsive  to  all  other  treatments ;  but  it  remains  for  us  to  define  clearly 
the  indications  for  it. 

•Heitz:  Des  troubles  circulatoires  qui  accompagnent  les  paralysies  ou  les  con- 
tractures post-traumatiques  d'  ordre  reflexe.  Archives  des  maladies  du  coeur,  Avril, 
1917,  p.  160. 

10  Recently  I  tried  to  arrest,  by  sympathectomy,  the  appearance  of  gangrene  after 
resection  of  the  popliteal  vessels.  The  operation  was  followed  by  complete  disap- 
pearance of  the  pains ;  it  changed  the  hue  of  the  violet-colored  spots  which  covered 
the  limb.  For  36  hours  I  hoped  for  a  therapeutic  result,  but  none  appeared,  and  I  had 
to  amputate  the  thigh. 


THE  EFFECT  ON  THE  WALLS  OF  BLOOD  VESSELS  OF 

PAETIALLY  AND  COMPLETELY  OCCLUDING 

BANDS  * 

It  was  very  gratifying  to  me  to  receive  about  a  year  ago  a  letter  from 
Dr.  Vaughan  announcing  that  he  had  successfully  placed  in  the  human 
subject  a  partially  occluding  band  of  tape  about  the  aorta. 

Those  are  in  error  who  have  stated  that  there  is  no  necrosis  of  the  aortic 
wall  under  the  partially  occluding  ligature  or  band.  The  included  portion 
of  the  wall  always  dies  whether  the  occlusion  is  partial  or  complete.  The 
danger  of  haemorrhage  is  greater  from  partial  than  from  complete  occlusion, 
for  in  the  former  case  the  only  protection  from  haemorrhage  is  a  new  con- 
nective tissue  capsule  which  after  a  time  embraces  the  band.  When,  however, 
the  occlusion  is  complete  the  necrosed  wall  may  become  converted  into  a 
cylindrical  fibrous  cord,  the  absorption  and  substitution  taking  place  by 
means  of  capillaries  which  penetrate  the  dead  wall  under  the  band  both 
from  above  and  from  below.  I  am  quite  sure,  as  I  have  repeatedly  stated, 
that  notwithstanding  much  testimony  to  the  contrary  union  between  intimal 
surfaces  of  a  large  artery  maintained  in  contact  under  ligatures  or  bands 
cannot  take  place,  for  the  compressed  portion  of  the  wall  of  the  artery  always 
becomes  necrotic. 

A  few  years  ago  Dr.  Reid  and  I  placed  partially  occluding  bands  about 
the  pulmonary  artery  and  were  interested  to  note  how  slowly  relatively  bands 
about  this  artery  cut  through  it.  In  one  dog  sacrificed  about  1^  years  after 
the  operation  we  found  that  the  metal  band  had  cut  through  only  along  a 
line  2  or  3  mm.  long  at  its  upper  edge  and  that  the  protecting  capsule  was 
firmest  just  over  this  linear  defect  in  the  wall  of  the  pulmonary  artery.  We 
assumed  that  the  delay  in  the  cutting  through  and  absorption  of  this  por- 
tion of  the  wall  of  the  artery  was  due  to  the  fact  that  the  pressure  from 
within  was  much  less  than  in  the  aorta,  and  this  being  so,  the  force  required 
to  occlude  the  pulmonary  artery  is  less  than  that  necessary  to  coarct  the 
aorta  to  the  same  degree.  With  this  idea  in  mind,  I  tested  on  dogs  about 
eighteen  months  ago  the  effect  on  the  wall  of  the  vena  cava  of  partially  and 
totally  occluding  metal  bands,  and  found  after  periods  of  six  or  less  months 

1  Brief  remarks  in  discussion  of  Dr.  George  Tully  Vaughan's  paper,  "  Notes  on  a 
case  of  ligation  of  the  aorta  two  years  and  one  month  after  operation."  American 
Surgical  Association,  Washington,  D.  C,  May  2,  1922. 

Tr.  Am.  Surg.  Ass.,  Phila.,  1922,  xl,  201-202. 


586  OCCLUDING  BAND  ON  BLOOD  VESSEL 

that  the  compressed  venous  wall  was  intact  and  thickened.  Hence  the  greater 
the  force  required  to  occlude  the  vessel,  namely,  the  greater  the  vascular 
pressure,  the  more  rapid  will  be  the  absorption  of  the  necrotic  wall.  When 
the  pressure  from  within  is  nil  or  so  nearly  nil  as  it  is  in  the  veins  the  band 
does  not  cut  through. 

It  will  be  interesting  to  determine  by  further  experimentation  and  micro- 
scopic study  of  the  specimens  the  processes  by  which  the  infoldings  of  the 
venous  wall  under  the  band  eventually  disappear — how  the  wall  of  the 
coarcted  portion  of  the  vein  loses  its  wrinkles  and  becomes  thickened. 


V.  \ 


£urc(ica4     popery, 


•i?^*